Psychological Review

© 2022 American Psychological Association 2023, Vol. 130, No. 3, 569–603

ISSN: 0033-295X https://doi.org/10.1037/rev0000398

Seeking Connection, Autonomy, and Emotional Feedback:

A Self-Determination Theory of Self-Regulation in
Attention-Deficit Hyperactivity Disorder
Rebecca E. Champ, Marios Adamou, and Barry Tolchard
School of Human and Health Sciences, University of Huddersfield

Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent and highly debated diagnosis
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for mental disorder in practice today. Two decades of research have substantially contributed to evolving
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conceptualizations and understanding of the condition. However, this evolution has not been extended to
theoretical research. Current cognitive behavioral-based theories aim to identify the etiology of ADHD and
experience challenges in accommodating the full spectrum of both neurobiological and behavioral research
evidence. Characterizations historically associated with mental illness have generated public stigma,
influencing low self-esteem, negative self-concept, and identity development in ADHD individuals.
Neurodiversity research and activism recognize a diversity of nonnormative development and highlight
the need for alternatives to deficit models of functioning. Recent research in psychology recommends
developing approaches beyond symptom control and seeking to develop positive psychological factors and
well-being. We propose that the perspective presented by self-determination theory (SDT) on human
motivation, self-regulation, and self-determination offers a new understanding of ADHD research evidence
and symptomology. According to this theory, humans have a natural tendency toward growth and self-
actualization. We propose a framework grounded in SDT that provides an alternative understanding of
ADHD neural processing, motivation and engagement, self-regulation, and a potential foundation for
treatment approaches with self-determination and positive identity outcomes.

Keywords: attention-deficit hyperactivity disorder, self-regulation, motivation, neurodiversity

Scientific objectivity is a critical element when interpreting clini-
cally relevant data. Although it is debatable whether pure objectivity
is attainable, it is a helpful heuristic for fostering scientific integrity,
particularly scientific experimentation, inference, and theory choice
(Reiss & Sprenger, 2017). In understanding and working with
neurodevelopmental disorders, the combination of psychological
theory and interpretation of research are critical influencers in clinical
treatment development and design. Highlighted is the essential nature
of identifying assumptions, beliefs, theories, and goals to guide
decision-making in attention-deficit hyperactivity disorder (ADHD;
Nigg, Karalunas, et al., 2020; Toplak et al., 2008).
Negative Self-Concept in ADHD
Initially characterized as a childhood disorder of behavioral
control, ADHD is now identified as a neurodevelopmental disorder
of self-regulation with significant impact in multiple dimensions
across the lifespan (Barkley, 2002; Bokor & Anderson, 2014;
Solanto et al., 2008). Undiagnosed and untreated ADHD confers
This article was published Online First December 22, 2022.
Rebecca E. Champ https://orcid.org/0000-0003-3771-5213
Barry Tolchard https://orcid.org/0000-0003-4137-9013
The authors have no conflicts of interest to disclose.
Correspondence concerning this article should be addressed to Rebecca
E. Champ, School of Human and Health Sciences, University of
Huddersfield, 7 Berristead Close, Wilburton, Ely CB6 3RS, United
Kingdom. Email: rebecca.champ@hud.ac.uk
a serious increased risk of adverse outcomes such as substance use,
psychosis and conduct disorders (Erskine et al., 2016; Groenman et
al., 2017; Kessler et al., 2006), educational and occupational failure
(Nigg, Sibley, et al., 2020), and late-onset psychiatric problems
including self-harm and suicide (Forte et al., 2020; Ljung et al.,
2014). If not addressed, ADHD can also have a significant economic
impact beyond the individual, in terms of increased healthcare costs,
decreased productivity, and risk of offending (Champ et al., 2021;
Kooij et al., 2019). Subthreshold cases of ADHD in childhood may
meet full diagnostic criteria in adolescents (Kooij et al., 2019).
However, due to the decline of hyperactive and impulsive symptoms
with age, some individuals may not have symptoms severe enough to
be diagnosed until adulthood, when executive function and atten-
tional difficulties become more salient. Many adults never receive a
diagnosis; instead, they have symptoms attributed to motivational or
intellectual deficits (Goodman, 2007). Studies examining healthy
individuals’ perceptions of ADHD show symptoms being childish
and inappropriate; presentation of behaviors increased tendencies of
peer rejection and feelings of hostility; and debates on antisocial
tendencies, prejudices around symptom etiology, and immediate and
long-term effects of the medication may contribute to stigmatization
(Mueller et al., 2012). The literature on the stigma associated with
mental illness emphasizes that the labeling of behavior as symptoms
of a mental disorder can create public stigma, leading to a reduced
ability to use cognitive resources to perform well (Forbes &
Schmader, 2010). Public stigma frequently results in self-stigma:
an internalization of a “new degraded identity” which negatively
affects self-esteem, self-efficacy, and impacts behavioral goals
(Corrigan et al., 2006; Fabrega, 1990; Kooij et al., 2019).

569
 570 CHAMP, ADAMOU, AND TOLCHARD
In addition, repetition and frequency of negative feedback on
ADHD behaviors from authority figures often generate a negative
self-concept at an early age (Young & Bramham, 2012; Young et al.,
2008). This association results in low self-esteem and a lack of trust
in making decisions or taking action without external validation of
the appropriateness of behavior or choice, which creates an uncon-
scious reliance on external structures or individuals for support.
Psychology defines this as contingent self-esteem (Blom, 2011;
Crocker & Wolfe, 2001; Ryan & Deci, 2000).
Theoretical Etiology of ADHD
A substantial amount of research has been conducted over the
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past 20 years, with significant advancements in neuroimaging,
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genetics, pharmacology, psychology, and the social sciences, dra-
matically changing the etiology and understanding of the symptoms
and impact of ADHD. Despite these advancements, etiological
theories are unable to account for all evidence entirely. Although
there are recognized neurobiological differences in ADHD, the role
of executive function (EF) is debated (Barkley & Brown, 2008;
Posner et al., 2020; Surman et al., 2015); heterogeneity remains
unresolved (Cordova et al., 2020; Nigg, Karalunas, et al., 2020;
Posner et al., 2020); and context variability, or interest-based main-
tenance of task engagement, is representative of ADHD challenges
with self-regulation (Brown, 2014; Hirvikoski et al., 2011; Roberts et
al., 2014). It is noticeable that there has been little reexamination of
the theoretical underpinnings of ADHD etiology in light of these
advancements. A recent scoping review highlighted that a single
etiological perspective based on cognitive–behavioral theory
forms the foundation for cross-disciplinary research in guidance
and treatment approaches for ADHD (Champ et al., 2021).
Cognitive–behavioral theoretical perspectives conceptualize ADHD
as having weak intrinsic motivation due to neurobiological impair-
ments with emotional self-regulation leading to challenges initiating
and persisting with goal-directed behavior (Barkley, 2014a).
This ADHD deficit-focused perspective is guided by cognitive–
behavioral models of self-regulation developed from mechanistic
frameworks which prioritize goal achievement supported by cogni-
tive control of emotional response and behaviors (Carver & Scheier,
2016; Gross, 2013, 2015). These models are grounded in psycho-
logical (or motivational) hedonism, which claims that all human
action and behavior aim at only increasing pleasure and avoiding
pain (Gosling, 1998; Moore, 2019). In these models, self-regulation
is synonymous with self-control, and a reduction in resources for
self-control is identified as ego depletion or deficits. Focus on
counteracting these deficits, or self-control strengthening, is a pri-
mary outcome of research and frameworks in these approaches
(Maranges & Baumeister, 2016). In ADHD, attributable behavioral
motivations are seen as approach and avoidance dynamics (Elliot,
2006) presented as deficits in attention, response inhibition, and
arousal resulting in low motivation, stimulus seeking, and task
avoidance, among others, ultimately informing treatment design,
aims, and outcomes. Although treatment approaches include some
techniques for identification and development of strengths alongside
symptom reduction and control, they only support clarification of
prevalence for diagnostic purposes, fewer impairments (Brites et al.,
2015; Crosbie et al., 2013; Greven et al., 2016, 2018; Smalley et al.,
2007) or identification of individual supportive strengths, as dem-
onstrated in cognitive–behavioral therapy and acceptance and
commitment therapy, and do not recognize any universal strengths
associated with ADHD (Barkley et al., 2008, 2010; Brooks, 2001;
Champ et al., 2021; Demontis et al., 2019; Dipeolu, 2011; Ramsay &
Rostain, 2008a; Ramsay et al., 2016; Table 1).
An emerging body of research on neurodiversity recognizes
diverse neurological presentations and promotes the perspective
that nonnormative patterns of neurodevelopment are not psycho-
logically unhealthy (Armstrong, 2010; Rosqvist et al., 2020a).
Defined as the infinite variation in neurocognitive functioning
within the human species, neurodiversity seeks recognition for
any significant embodied divergence from dominant cultural norms
of neurocognitive functioning (Walker, 2021). Neurodiverse activ-
ism criticizes the discourse of patterns of cognitive “normality” and
promotes a recognition of conditions that impact the identity of an
individual alongside differences in perceiving and responding to the
world (Fenton & Krahn, 2007; Rosqvist et al., 2020a; Waltz, 2020).
Recent research in psychology also suggests that treatment ap-
proaches focusing on deficits and residual symptoms may not be
the best approach to improve mental health, and it may be necessary
to develop positive psychological factors and emotions that culti-
vate health, well-being, and support psychological growth (Dell
et al., 2021; Jacob, 2015; Liberman, 2008; Slade, 2010). Self-
determination theory (SDT) is an organismic-dialectical approach
to human motivation and development (Ryan & Deci, 2017). SDT
views self-regulation as an evolving process of internalization and
integration of intrinsically motivated self-determined actions lead-
ing to self-organization (Ryan et al., 1999). In contrast to the
cognitive–behavioral theory, the roots of SDT lie in the core concept
that living things have an organizational nature with inherent growth
tendencies. From this perspective, the SDT definition of well-being,
or flourishing, consists of more than just the experience of hedonic
positive emotions. It originates from pursuing a life of activity that is
subjectively satisfying developed from and expressing the most
reflectively valued and well-integrated human potentialities, a eu-
daimonic view of wellness (Deci & Ryan, 1985; Ryan & Deci, 2017;
Ryan et al., 2013). According to this theory, this inherent human
tendency to act volitionally and engage with the environment to
achieve integration requires social and environmental support to
satisfy basic psychological needs, and developing an individual
awareness of these needs is central to healthy self-regulation
(Ryan & Deci, 2017). SDTs alternative theoretical perspective on
human motivation offers the opportunity to reevaluate the potential
strengths of ADHD, reinterpret ADHD research, and develop new
treatment approaches with outcomes that include integration and
flourishing. To understand the development of the etiology of
ADHD, we begin with a short history of theoretical development.
An overview of the current main theories of ADHD is followed by a
critical review based on current research. Finally, we discuss SDT as
a theory and present a potential framework for an SDT-based
ADHD etiology and treatment approach.
Theoretical Development: Disorder to Syndrome
Disorder: /dɪsˈɔːdə/noun An illness or condition that disrupts normal
physical or mental functions. (Oxford University Press, n.d.-a)
The clinical view of approaching, understanding, and working with
ADHD has a complicated history, heavily derived from social-
cognitive and cognitive–behavioral theory and practice. Initially,
identification of this collection of behaviors arose from a frame of
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Table 1
Comparison of ADHD Etiological Theories

Theoretical models of ADHD

Key differences Barkley Brown Sonuga-Barke Sonuga-Barke Sagvolden Nigg et al. Champ et al.

Definition of Challenges in self- Challenges with Challenges with Challenges with Challenges with altered Challenges with Challenges with
impairment regulating arousal engagement in inhibitory control inhibitory control reinforcement of accurate predictions acquisition and
concerning goal- successful self- delayed gratification delayed gratification novel behavior and resulting in difficulty
application of
directed behavior and regulating behavior generating generating deficient extinction of adjusting behavior tocognitively dominant
difficulties using attention and motivational deficits motivational deficits reinforced behavior what is presented skill sets,
maintaining attention memory to guide resulting in resulting in when something susceptibility to
for tasks with little to action preference for preference for unexpected happens salient and affective
no reinforcement or immediacy immediacy stimuli, and
immediate reward maintenance of
motivation and task
engagement in
autonomy depriving
and thwarting
contexts and
environments
Neurobiological Deficits in hierarchical Developmental Dysregulation of action Dysregulation of action Dysregulation of tonic/ Developmental Affect dominant and
origin maturational impairment of and thought resulting and thought resulting phasic dopamine impairments in inefficient cognitive
development of EF unconscious from poor inhibitory from poor inhibitory control causes stunted reinforcement, self-regulatory
and control. Caused automatic cognitive control associated control associated dopamine phasic reward, and effortful processes,
by abnormalities in network guidance with the meso-cortical with the meso-cortical responses despite regulation reliant on overinclusive
structure, function, systems of dynamic branch of the branch of the low-tonic levels. affect-related neural processing style, and
and bio-chemical EF clusters. Caused dopamine system dopamine system Affects the systems that detect altered temporal
operation of fronto- by differences in projecting in the projecting in the functioning of the events’ emotional processing. Caused
parietal and fronto- parieto-temporal cortical control cortical control anterior cingulate, significance. Caused by reduced volumes
striatal neural activation and centers (EF). Altered centers (EF). Altered dorsolateral prefrontal by deficits in in cognitive control
networks fronto-striatal and delay-of-reward delay-of-reward and motor circuits, maturation of top- networks and
fronto-cerebellar gradient linked to the gradient linked to the and subsequently a down cortical prolonged
connectivity, meso-limbic meso-limbic variety of behaviors projections from PFC development and
impairments in dopamine branch dopamine branch impairing hypofunctioning
default-mode associated with the associated with the differentiation of dopaminergic systems
deactivation, reward circuits (e.g., reward circuits (e.g., cognitive and neural impacting time
neurodevelopmental NAccs) NAccs) systems awareness and
ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY

delay in maturation, resulting in

and inadequate hyperconnectivity to
release and control of SN and
dopamine and semisuppression of
norepinephrine DMN in cognitive
task engagement
Foundation of Neurobiopsychosocial Clinical interview Laboratory testing of Laboratory testing of Behavioral research Developmental Organismic-dialectical
model theory of EF as research of individuals with individuals with with animal models behavioral theory of human
psychological individuals with ADHD ADHD temperament theory motivation and
construct separate ADHD and their of personality traits development
from neurological families
functions
Impact of Disruption to EF Impairments to EF in Negative feedback on Negative feedback on Individual variations in Breakdowns or Variable interest-
impairment extended phenotype unconscious impulsive behaviors impulsive behaviors dopamine functioning disruption in linking dependant experience
levels adversely automaticity create and poor performance and poor performance on learning processes the known correct of need frustration or
571

impacting behavioral disruption in over time generates over time generates and behavior result in behavior with the amotivation in task
control resulting in activation delay aversion or delay aversion or developmental delays current context leads engagement.
(table continues)
 572 CHAMP, ADAMOU, AND TOLCHARD

with use of cognitive-

mental illness. In North America in the 1960s, the first shift in the

estimation interfering
embodied time leads

organizational skills.

motivational coping
dopaminergic stress
to over- or under-

Note. ADHD = attention-deficit hyperactivity disorder; EF = executive function; NAccs = nucleus accumbens; PFC = prefrontal cortex; SN = salience network; DMN = default-mode network.
Champ et al. perspective around these behaviors appeared: the concept of hyper-

dependence on
Distortions in activity changed from an extreme state of excessive activity to a

response as a
Overreliance or
unconscious
behavioral syndrome of more significant than moderate activity

dominant

strategy
and an extreme but common disturbance in childhood. This concept
diverged significantly from Europe, particularly Great Britain, which
continued to view hyperactivity as uncommon, extreme, and usually
associated with brain damage. This shift would substantially impact
thoughts and actions
resulting in less top-

differing views of prevalence, diagnostic criteria, and treatment for

regulation of affect
recruited, affecting

the next 20 years (Prendergast et al., 1988; see Figure 1).

down cognitive

maintenance of
Nigg et al.

over time, and

control being
expectations,
to inaccurate

Dissatisfaction with a lack of objective measures for these

planning,

behaviors led to more detailed research. The work of Virginia

Douglas (Douglas, 1972, 1980a, 1980b, 1983; Douglas & Peters,
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1979) effectively presented the first model of attention deficit by

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introducing several key concepts of deficits. Barkley (2014b, p. 13)

instructional demands

behaviors and lack of

and behavior, leading

later summarized these as follows:

situationally relevant
connections between

development of self-
directed speech for
guiding behavior

1. “the investment, organization, and maintenance of

Sagvolden
in identifying

situational or

attention and effort;

to problems
anticipating
appropriate

2. inability to inhibit impulsive responding;

3. inability to modulate arousal levels to meet situational

Theoretical models of ADHD

demands; and
functional expressions

protection, and use of

delay aversion related

of motivational delay
avoidance or escape.

secondary effects of
negative emotional

4. unusually strong inclinations to seek immediate

to patterns of task
response to delay.

Cognitive deficits
Sonuga-Barke

with provision,

reinforcement.”
Behaviors are

time arise as

engagement

The impact of this article and the subsequent research that

followed resulted in a change in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) of the name “hyperkinetic
impulse disorder” to “attention-deficit disorder” and ADHD in the
functional expressions

delay aversion related

protection, and use of

DSM-IV (APA, 1980, 1987). Douglas’ original research formed the

of motivational delay
avoidance or escape.

secondary effects of
negative emotional

foundation for investigations into an underlying deficit in self-

to patterns of task
response to delay.

Cognitive deficits
Sonuga-Barke

with provision,

regulation (Barkley, 1997a) and further research by Douglas pointed

Behaviors are

time arise as

engagement

out the high degree of relationship between these deficits and

response to stimulant medication across all four domains
(Douglas, 2005).
Syndrome: /,ˈsɪndrəʊm/noun A group of symptoms which consistently
occur together, or a condition characterised by a set of associated
effort, and processing

(managing frustration

accessing recall), and

monitoring and self-
regulation), memory
alertness, sustaining

symptoms. (Oxford University Press, n.d.-b)

shifting attention),

(utilizing working
activating action),

effort (regulating

regulating action
focus (focusing,

speed), emotion
estimating, and

sustaining, and

Although there was general agreement that ADHD must be

Brown

memory and
(organizing,
prioritizing,

and general

associated with cognitive deficits, Douglas’ model identified a

pattern of behaviors but could not explain their origin. Continued
empirical research began to cast doubt on the central focus on
problems with attention in ADHD due to the situational variability
of symptoms and the lack of substantial evidence for deficits
gratification, impaired

involving perception, filtering, and processing of information.

impaired sense of

impaired intrinsic
verbal problem-
self, inability to
contemplate the

Also critical was the separation of ADHD, conduct disorder, and

future or delay

reasoning, and
Barkley

oppositional defiant disorder (Wender, 1995). Early studies of

solving and

motivation

“hyperactivity” failed to distinguish these disorders as separate

and characterized ADHD with these behaviors as standard. There-
fore, this literature is more relevant to childhood “externalising
Table 1 (continued)

behavior problems: for example, hyperactivity and aggression or

Key differences

hyperactivity and conduct disorders” (Loney & Milich, 1982,

p. 143) rather than ADHD alone. Investigators were increasingly
examining motivation and sustained efforts to conceptualize pro-
blems experienced by those with ADHD (Barkley, 2014b; Douglas,
1989; Slusarek et al., 2001).
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY 573

Figure 1
Timeline of Changes in Etiology of ADHD
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Note. ADHD = attention-deficit hyperactivity disorder; DSM-II = Diagnostic and Statistical Manual of Mental Disorders, Second Edition; DSM-III =
Diagnostic and Statistical Manual of Mental Disorders, Third Edition; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition;
DSM-V = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ICD-8 = International Classification of Diseases, Eighth Revision; ICD-9 =
International Classification of Diseases, Ninth Revision; ICD-10 =International Classification of Diseases, Tenth Revision; PET = positron emition
tomography; MRI = magnetic resonance imaging. See the online article for the color version of this figure.

ADHD Evidence: Genetic and Neurobiological Research
In the late 20th and early 21st century, research on ADHD
continued to be cognitively focused and advances in imaging and
neurobiological studies influenced how ADHD was perceived.
There was a removal of the association between ADHD and brain
damage symptoms due to a lack of neurological abnormality evi-
dence (Barkley, 2014b; Ramsay, 2010). Single-photon emission
computed tomography (SPECT) indicated decreased blood flow in
the prefrontal regions and connecting pathways to the limbic system
via the striatum, specifically the anterior caudate and cerebellum.
SPECT imagery of dopamine transporter indicated lower dopamine
transporter levels in medication-naive patients (Fusar-Poli et al.,
2012; Volkow et al., 2009). Positron emission tomography demon-
strated that methylphenidate blocks dopamine and norepinephrine
transporters, increasing the dopamine in the synapse and amplifying
the saliency value of stimuli (Volkow et al., 2005). Structural brain
imaging showed reduced total/whole brain and gray matter volume
(Albajara Sáenz et al., 2019), with abnormal volumes in gray matter
in several areas, including the right frontal and prefrontal areas
(Depue et al., 2010; Pironti et al., 2014), anterior cingulate (Amico
et al., 2011; Frodl & Skokauskas, 2012; Makris et al., 2010), basal
ganglia and cerebellum (Almeida Montes et al., 2010; Makris et al.,
2015; Proal et al., 2011; Seidman et al., 2011), and visual cortex
(Ahrendts et al., 2011). Several studies have identified subcortical
brain volume differences with the most consistent findings showing
reduced volumes in areas of the basal ganglia, specifically involving
the right lentiform nucleus (putamen and globus pallidus) and the
caudate nucleus (Ellison-Wright et al., 2008; Hutchinson et al.,
2008; Norman et al., 2016; Valera et al., 2007). Significantly smaller
volumes were identified in the accumbens, amygdala, caudate,
hippocampus, and putamen in children confirming brain maturation
delay; however, the effect sizes were small with the exception of the
amygdala (Hoogman, Bralten, et al., 2017). Cortical thickness also
appeared reduced in adults with ADHD (Almeida et al., 2010;
Duerden et al., 2012; Proal et al., 2011) as well as volume and
surface area in young people, although developmental patterns were
similar to controls (Ambrosino et al., 2017; Silk et al., 2016).
Evidence for structural deficits involving interconnections between
large-scale brain networks from diffusion tensor imaging (Cortese et
al., 2013; Konrad et al., 2010; Liston et al., 2011; Van Ewijk et al.,
2014) was attributed to microstructural abnormalities in white matter
tracts in the cingulum, isthmus, fronto-occipital, frontostriatal, tem-
poral, and temporo-occipital fasciculi with atypical hemispheric
connection most commonly identifed in the corpus callosum (Aoki
et al., 2018; Cortese et al., 2013; Dramsdahl et al., 2012; Konrad et al.,
2012; Onnink et al., 2015; Shaw et al., 2015). There were also
indications of more significant inattention symptomology associated
with lower microstructural integrity in the left uncinate and inferior
fronto-occipital fasciculi than controls (Shaw et al., 2015).
Functional MRI (fMRI) meta-analysis identifies dysfunctions in
several areas of the motor inhibition network (Lei et al., 2015).
Studies indicated that hypoactivation is described as “deficient
fronto-striatal activation” when compared to controls in the
fronto-parietal executive control network, putamen, and ventral
attention network (Cortese et al., 2012, p. 1051). Hyperactivations
in regions of the default-mode and optical networks and consistent
underactivation compared to controls in fronto-cerebellar networks
for timing functions (Hart et al., 2012) as well as abnormally
enhanced activation in default-mode regions (Hart et al., 2012),
inferior fronto-striatal networks during cognitive tasks (Hart et al.,
2013), and dorsolateral fronto-striato-parietal networks during atten-
tion tasks (Cai et al., 2021; Hart et al., 2013) were perceived as faulty
regulation of relationships between default-mode and task-positive
 574 CHAMP, ADAMOU, AND TOLCHARD
networks (McCarthy et al., 2014; Sonuga-Barke & Castellanos,
2007). Differential task activations during inhibition, attention, or
working memory tasks appeared in regions overlapping the intrinsic
fronto-parietal, dorsal attentional, visual, motor, and default-mode
networks (DMNs) in ADHD compared to controls (Castellanos &
Proal, 2012; Lei et al., 2015). Abnormally enhanced functional
connectivity between limbic and orbitofrontal regions during emo-
tional processing, both positive and negative, indicates emotional
hyper-responsivity (Rubia, 2018), and local efficiency and cluster-
ing of the right insula are positively associated with emotional
dysregulation, particularly with the hyperactive presentation of
ADHD (Viering et al., 2021).
Genetic studies also indicated that ADHD has high heritability
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(Franke et al., 2012; Kooij et al., 2019), a co-occurrence or overlap
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with autistic spectrum disorder (Ghirardi et al., 2018; Miller et al.,
2019), intellectual disability (Faraone et al., 2017), communication
and learning disorders (Thapar et al., 2017), and heritable phenotypes
including anxiety and depression and health risk behaviors such as
smoking, obesity (Demontis et al., 2019), and alcoholism (Derks et
al., 2014). A strong correlation between ADHD diagnosis and trait
scores in the general population demonstrated that ADHD represents
the extreme of a continuously distributed trait (Demontis et al., 2019;
Faraone & Larsson, 2019; Middeldorp et al., 2016). Literature
published during and after this time show a shift in how professionals
and researchers describe ADHD based on this ongoing research:
The genetic explanation of ADHD has an important implication that can
easily go overlooked: ADHD may simply represent an extreme form of
a normal human trait and not a pathological condition in most cases.
(Barkley, 2005, pp. 75–76)
Consequently, rather than being a disorder of the 21st Century, ADHD
is an ageless syndrome, likely having been present ever since there has
been a human brain. (Ramsay, 2010, p. 11)
Current Theories of ADHD
Douglas (1972) model set the stage for self-regulation as a core
deficit in ADHD, but it constituted a psychological model of
behavior rather than a theory of ADHD. Barkley (1998) postulated
the first unifying theory of ADHD, which places a core deficit of
behavioral inhibition at the source of ADHD behaviors. Strongly
based on Skinnerian principles, Barkley reframed issues with
attention and impulsivity as stimulus control problems in a relation-
ship between a stimulus and behavior (Barkley, 1989; Mash &
Barkley, 2006). Barkley’s executive dysfunction theory suggests
deficits in four key areas: working memory, emotional regulation,
internalization of language, and reconstitution, or creation of novel,
complex goal-directed behaviors (Barkley, 1997b, 1998; Willcut,
2014). As an extended phenotype theory, Barkley’s model is built
upon observation of perceived chronic difficulties in behavior,
measured as “excessive or inappropriate for their age or develop-
ment level” (Roberts et al., 2014, p. 63). These symptoms present in
two dimensions: hyperactivity/impulsivity and inattention.
EF Theory Perspective on Self-Regulation
Barkley’s (1997b, 2012) theory defines EF as a psychological
construct separate from the traditionally presented neurological
functions. At its core are four critical theorists: Bronowski, Fuster,
Goldman-Rakic, and Damasio. Bronowski’s (1977) theory of the
uniqueness of human language describes four unique human mental
abilities attributed to the prefrontal cortex (PFC): prolongation,
separation of affect, internalization, and reconstitution. Fuster’s
(1997) theory of prefrontal lobe functions emphasizes EFs’ temporal
integration and orientation toward the future. Goldman-Rakic
(1995) argues that activation and use of visual representations of
the world and the storage of those representations for behavior
regulation are significant functions of the PFC. Damasio (1994,
1995) postulates that a critical component of decision-making in the
prefrontal lobes is a cost–benefit analysis supported by emotional
and motivational information provided by somatic markers. Bark-
ley’s theory uses constructs from behavioral and social-cognitive
theories of personality and functioning, goal theory, socioeconomic
theory, and neuropsychological models of executive functioning
and evolutionary psychology.
Barkley’s foundation of self relies on Skinnerian radical operant
conditioning (Skinner, 1953). In this theory of personality, the
concept of self, or everything an organism does in response to a
stimulus, is defined as behavior (Skinner, 1971). Barkley cites Von
Mises (1990) economic model and objectivism (Piekoff, 1993) as
sources for definitions of means or action toward goals or values.
Goals are states resulting in decreased dissatisfaction or unease
relative to the present state and future states that we seek to attain,
fulfill, and retain. Barkley defines wants and desires as these future
states that we value because they increase satisfaction, happiness,
and welfare (Piekoff, 1993). Energization and direction of behavior
are motivated by movement to change the present state to a future
improved state, toward, or away from pleasure or pain—a hedonic
view of wellness which is a common theme in social-cognitive
theories of functioning (Carver & Scheier, 2016; Mischel & Shoda,
1995). According to Von Mises (1990), the utility or use value of a
goal is subjective or objective, with subjective being individually
evaluated. The degree to which the individual perceives a goal to
alleviate dissatisfaction will determine its value and drive goal-
directed actions and behavior. The course of action pursued to attain
that goal is defined as the means to that end. Barkley equates this
individual evaluation for choices and actions with self-regulation or
self-control. EF and self-regulation in this model are therefore
directly linked to forward projections of effect in linear time: an
executive act is any action an organism takes to modify behavior
predicting it will change future outcomes (Barkley, 2015).
The Six EFs
For Barkley, the ability to evaluate subjective goals correlates to
EFs, which he defines as “those self-directed actions needed to
choose goals and to create, enact and sustain actions toward those
goals” (Barkley, 2012, p. 60), a view echoed in neuropsychology
(Eslinger, 1996; Wagner & Heatherton, 2011). Barkley describes six
forms of EF that are interactive and serve the common purpose of
internalizing self-directed behavior to rehearse actions to test prob-
able consequences mentally. In particular, it allows for assessing
emotional responses, defined by Barkley as somatic markers
(Damasio, 1994, 1995), to determine social acceptability.
Muscular–skeletal manifestations of behavior initially observable
in childhood are inhibited by EFs through maturation to form private
behaviors in adulthood to align with social–cultural norms. Man-
agement of social conduct by EF, specifically the PFC, is
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
highlighted as the evolutionary purpose of self-regulation (Barkley,
2012; Eslinger, 1996). Therefore, these abilities facilitate adaptive
functioning by anticipating and preparing for future action through
an internal trial-and-error process (Barkley, 2015).
The six forms of EF or self-directed actions are hierarchically
arranged as follows:
1. Self-directed attention (self-awareness). Self-directed
attention is the first to arise and forms the conscious
sense of “self.” Barkley places self-awareness as the
“central executive” seat responsible for the coordination
of cognitive processes, similar to Stuss and Alexander
(2000) and in contrast to other models of EF. This EF
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provides the awareness of values and wants and the
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capacity to generate and consider options available to the
individual over time, making it the “seat of human free
will” (Barkley, 2012, p. 29). Evidence for self-awareness
as a brain function primarily centered in the PFC and
connected networks is drawn from three sources:
diminished self-awareness following brain injuries,
specifically to the PFC (Stuss & Alexander, 2000),
Damasio’s neurobiological triumvirate model (Damasio,
2000), and neuroimaging research (Herwig, 2010).
2. Self-restraint (executive inhibition). Executive inhibition
provides the delay or temporal gap required for self-directed
actions, or goal-directed behavior, to arise. Separation of
the event from the sensorimotor responses of future activity
exemplifies the decoupling of stimulus–response behavior
required for attention to be shifted away from the present
moment environment and directed toward the self and the
goal, or contemplated future (Barkley, 2015). This EF
represents the separation of affect in Bronowski’s (1977)
theory, and Barkley locates this at the automatic level of
brain functioning, incorporating the frontal–striatal cir-
cuitry and basal ganglia (Saint-Cyr, 2003).
3. Sensing the self (nonverbal working memory). This EF is
conceptualized as a self-directed action to use visual
imagery or imagination. Often compared to Baddeley’s
(1986; Baddeley & Hitch, 1994) visual–spatial sketch pad,
Barkley combines this concept with Vygotsky’s (1978,
1987) theory of the development of private speech to
suggest a visual form of self-guidance and direction, or
“cool EF” (Castellanos et al., 2006) that becomes progres-
sively internalized with maturation. This EF has two roles:
the frontal lobe enables access to past sensory experiences
and links them to covert prospective preparatory motor
elements to mentally rehearse options for future responses
(Fuster, 1997; Goldman-Rakic, 1995) and experiences can
then be self-elicited in the absence of the primary stimulus
for behavioral reenactment or mimesis. Barkley considers
the ability of this EF to bridge cross-temporal elements
crucial for self-control. The foundation of this EF is a
prolongation, from Bronowski’s (1977) theory, linked
with the right dorsolateral PFC (DLPFC) and posterior
visual association areas (D’Esposito et al., 1995, 1997).
4. Speech to the self (verbal working memory). Baddeley’s
(1986) construct of a phonological loop is the basis for this
575
EF, to which Barkley again adds Vygotsky’s model of
internalization of speech which forms the ability of self-
control via language through covert self-description self-
instruction, self-questioning, and problem-solving. This
loop invents rules and metarules for oneself (Diaz & Berk,
1992), but Barkley also suggests that it is responsible for
maintaining moral conduct or internalizing socially pre-
scribed rules. This “cool EF” (Castellanos et al., 2006)
represents the internalization in Bronowski’s (1977) the-
ory and activates the same prefrontal regions used for
audible speech (Ryding et al., 1996).
5. Self-directed appraisal (emotion/motivation to the self).
Arising from the first three EFs, this EF represents affec-
tive and motivational valences, or hedonic tone, associated
with visual and verbal information. These valences are
Damasio’s (1994, 1995) “somatic markers.” They indicate
the intrinsic “goodness” or “badness” of an event, object,
or situation related to homeostasis, generating the motiva-
tion to move toward satisfaction and away from dissatis-
faction. Similar to the previous EFs, Barkley defines these
valences as emotional displays that eventually move from
visible to covert through maturation, transforming from
reactions to an internalized motivationally guiding force,
or the “wellspring of intrinsic motivation” (Barkley, 2015,
p. 415). With the support of the previous three EFs,
emotions are responses to environmental stimuli and
states created as needed as self-motivation or “hot EF”
(Castellanos et al., 2006). These states initiate and sustain
action toward future goals, attributed to bidirectional net-
works linking the DLPFC, orbitofrontal cortex, anterior
cingulated cortex, and amygdala (Damasio, 1994, 1995;
Etkin et al., 2006; K. N. Ochsner et al., 2009; K. N.
Ochsner & Gross, 2005; Rushworth et al., 2007).
Combined with the previous three EFs, mainly nonverbal work-
ing memory, this EF provides the persistence (sustained attention)
and willpower to support the attainment of future goals. Barkley
defines this capacity to inhibit immediate behavior favoring future
outcomes, or delay gratification, as a conscious executive appraisal.
From this perspective, the ability to contemplate “later” versus
“now” makes the action of choice a biological function to support
goal-directed behavior. This action includes emotional self-
regulation in choosing to inhibit strong emotional displays to
appropriately respond to a social context, meet social demands,
and maintain relationships.
6. Self-play (reconstitution). The final EF completes Bark-
ley’s model basis on Bronowski (1977). This EF conveys
the ability to take apart (analysis) and recombine
(synthesis) information to form novel combinations of
behaviors, defined in Barkley’s model as problem-
solving. Behavioral innovation, flexibility, generativity,
and planning for goal-directed action from a present state
to the desired state are all attributed to this EF, and
Barkley describes this as a process of action fluency (Piatt
et al., 1999) or the ability to retrieve verbs impaired in
frontal lobe injury. Barkley locates this alongside verbal
and nonverbal working memory in separate DLPFC
regions (Lee et al., 1997; Stuss & Alexander, 2000).
 576 CHAMP, ADAMOU, AND TOLCHARD

Extended Phenotype Model of EF
As self-regulatory processes, Barkley suggests each EF contri-
butes to adaptive functioning in the species’ phenotype (Dawkins,
1982), which critically impacts social activity and individual sur-
vival and welfare. Figure 2 represents the effect of the outward
extension of the EF phenotype into personal, social, community, and
cultural activities (Barkley, 2012).
Preexecutive and Executive Levels of Functioning
The extended phenotype model is hierarchical and includes six
functioning levels, dependent on attaining the previous level for
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temporal “now” and in the immediate environment outside of
self-awareness or self-consciousness. Primary emotions occur at
this level that may heighten attention and redirect behavior to
immediate well-being situations. However, Barkley perceives this
as a primitive, unthinking, unreasoning animal-like level of exis-
tence, and does not consider these responses forms of self-regulation
and therefore not EF (Barkley, 2012).
Instrumental-Self-Directed Level. The six self-directed ac-
tions of EF are at the instrumental-self-directed level of the model.
Self-direction and internalization are taken from Vygotsky’s model
(Diaz & Berk, 1992; Vygotsky, 1978, 1987), causing this level to
arise from the preexecutive through human development musculo-
skeletal movements’ expression and action to become private and

emergence, identified as means of self-control, or classes of action “cognitive.” This representation of the executive level exerts effort-
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self-directed to make choices and improve the future.
Preexecutive. The preexecutive level of the model contains the
“automatic” or largely unconscious level of human activity seen in
feedback loop theory (Carver & Scheier, 2016), Gross’s emotional
self-regulation model (Gross, 2007, 2013; K. N. Ochsner & Gross,
2005), attentional control models (Rueda et al., 2011), and the
concept of effortful control (Eisenburg et al., 2011). It represents
neuropsychological functions responsible for the operant condition-
ing behavior with stimulus structure—response—consequence
(Skinner, 1953), moment-to-moment actions directed to the
ful control to cause the “top-down” regulation of automatic actions
through generation and sustainment of mental representations of the
future (Carver & Scheier, 2016; Eisenburg et al., 2011). In current
cognitive theory, “top-down” self-regulation is influenced by cog-
nitive regulation skills managed by EFs demonstrated as intentional
cognitive control (Carver & Scheier, 2016). Emotional regulation is
considered as a less intentional and more reactive “bottom-up”
influence which can be helpful and unhelpful. Metacognition, or
self-monitoring, is considered essential to self-regulation for self-
evaluation, task difficulty, performance, and strategy acquisition

Figure 2
Barkley’s Extended Phenotype Model of EF

Note. EF = executive function. Adapted from “Executive Functions: What They Are, How They
Work, and Why They Evolved,” by R. A. Barkey, 2012. Guildford Press. Copyright 2012 by
Guilford Press. Adapted with permission. See the online article for the color version of this figure.
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
(Fernandez-Duque et al., 2000). The integration of cognitive regu-
lation and emotional regulation to regulate behavior and actions are
the central work of self-regulation, and these domains influence one
another in a bidirectional relationship (Blair & Ursache, 2011).
Barkley cites Gross’s (2007) modal model and Carver and
Scheier’s (2016) feedback loop theory as two equivalent self-
regulation models. In Gross’s modal model, Barkley compares
the executive level pathways of emotional control as methods the
EFs use to influence automatic behaviors via five vectors: situation
selection, situation modification, attentional redirection, event reap-
praisal, and response modification/suppression (Gross, 2007). The
first two stages are proactive, decreasing the likelihood that an
unwanted primary action/emotion will occur. The remaining three
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are reactive and potentially less effective as a primary action/
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emotion has been elicited, and there is a limited resource pool of
willpower which can become depleted in the process (Bauer &
Baumeister, 2011). This process can be used both to self-regulate
strong negative emotions and enhance or prolong positive emotions
through methods such as mental contrasting—visual images of the
desired state/goal contrasted with the present state—thus creating a
form of emotional self-control (Gollwitzer & Oettingen, 2011). In
Carver and Scheier’s multisystem feedback loop model, Barkley
compares EFs self-directed action with the discrepancy reduction
monitoring between the present and desired state/goals. As emotions
in Barkley’s model provide motivational indicators of progress
toward goals, Carver and Scheier’s (2016) model uses emotional
markers to measure variation in rates and velocity of progress
toward goals. Barkley also maps EFs components to the two-level
emotional feedback loop model as the executive level of effortful,
conscious, deliberative, and rational goal-directed action that alters
or overrides the automatic, experiential, unconscious, and intuitive
level if one’s actions become inappropriate to the situation or goal.
Barkly has a particular economic view of self-directed behaviors,
differentiating between leisure and labor (Von Mises, 1990). Self-
directed actions that are pleasurable or reduce dissatisfaction can be
ends in themselves but are not EF if there is no modification to goal-
directed behavior or alter delayed consequences. Barkley classes
these as potentially maladaptive because they may interfere with
long-term goals and welfare, such as mind wandering/daydreaming
interfering with completing a task on time (Barkley, 2012).
Methodical-Self-Reliant Level. This model’s level extends the
analysis and synthesis into recombination from the self-directed
level to sequences of actions within the physical environment, such
as routines. Barkley (2012, 2014a) argues that this is the basis for
human productivity and innovation to effectively attain goals and
increase one’s quality of life and long-term welfare through envi-
ronmental reorganization. The ability to self-organize and act
beyond internal executive cognitions is the hallmark of this level.
Tactical-Reciprocal Level. This level represents social reci-
procity and the organization of the social environment for goal
achievement. Effective moral and ethical rules of social conduct
require inhibition of self-favoring others and long-term welfare for
circumstances where goals cannot be achieved alone. The ability to
engage in behaviors that support effective social exchange for
mutual benefit over the longer term such as sharing, taking turns,
and accepting social etiquette, which Barkley (2012) states is
challenging for individuals with PFC injuries (Harlow, 1848,
1868; Luria, 1966) and affects individual self-regulation (Finkel
577
& Fitzsimons, 2011; Fitzsimons & Finkel, 2011; McCullough &
Carter, 2011).
Strategic-Cooperative Level. Barkley separates this level
from the previous level as he equates cooperation with a conscious
understanding of the division of labor and increased sacrifice of self-
interest to obtain greater personal benefit leading to acceptance of
interdependence. Conscience, sympathy, empathy, guilt, remorse,
and a sense of belonging are defined as psychological capacities
arising from and facilitating social cooperation (Barkley, 2012).
Specialization in skills based on the talent through foresight and
reasoning arises at this level and trust, investment, and behavior
based on laws and ethics. Social mutualism, or placing others’ self-
interest over or ahead of one’s own, characterizes this level.
Extended Utilitarian Level. Barkley’s final level acts as a
feedback mechanism for EF successful use or self-regulation from
the previous levels. Evidence for successful individual use of EF is
demonstrated in the extension of life expectancy, economic and
social success, and long-term welfare of offspring. Conscientious
behavior, or considering the consequences to self and others over
impulsiveness and selfishness, prevents premature death, promotes
positive judgment and feedback from others, ensures professional
advancement, improves parenting abilities, and ensures economic
resources to support future generations. Barkley supports this with
research on the negative impact of ADHD on daily life activities
generally (Barkley, 2011), and specifically including marriage and
relationships (Barkley, 2008; Ninowski et al., 2007) and parenting
(Banks et al., 2008; Barkley, 2006; Murray & Johnston, 2006).
EF Theory Perspective of ADHD
Barkley’s theory prioritizes two key elements: the core of EF or
self-regulation: the self-direction of self-regulation of actions across
time for goal attainment and internalization of those self-directed
actions (Barkley, 2012). From this perspective, Barkley believes
that ADHD demonstrates apparent deficits. There are observable
challenges in self-regulating arousal concerning goal-directed
behavior and difficulties maintaining attention for tasks with little
to no reinforcement or immediate reward (Barkley, 1997b, p. 68).
According to Barkley, deficits in the hierarchical maturational
development of EF in ADHD are predicted to disrupt this extended
phenotype’s various levels, adversely impacting the sources of
control over behavior. In other words, ADHD will interfere with
the biological action of choice and, therefore, a loss of freedom and
self-determination (Barkley, 2012). This interference results in an
• Impaired sense of self, including self-awareness and self-
monitoring.
• Inability to contemplate the future, resulting in reduced
hindsight, forethought, and the creation of anticipatory
action toward future events. This inability impacts the
ability to organize and execute actions to achieve goals
concerning time and engage in imitation and vicarious
learning.
• Inability to delay gratification, leading to impulsivity, or
inability to subordinate self-interest to others or long-term
personal goals; and distractibility, or failure to inhibit
responses to a task or goal-irrelevant events.
 578 CHAMP, ADAMOU, AND TOLCHARD
• Reduced behavioral self-control because of greater public
and less private self-speech and reflection before acting,
impairing verbal problem-solving and reasoning. Barkley
implies that this includes difficulty following rules and
instructions and other ethical guides for conduct.
• Impulsive, emotional expression and reactivity, interfering
with top-down emotional regulation processes in the ser-
vice of long-term goals, including situation selection and
modification, attention deployment, cognitive reappraisal,
and response suppression or modification (Gross, 2007).
Somatic marker-based decision-making would also be
impaired (Damasio, 1994, 1995).
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• Impaired intrinsic motivation or diminished internal ability
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to induce drive or motivational states toward goals, result-
ing in a dependence on the external environment for
motivation. Without external motivators, sustained atten-
tion and persistence become erratic.
• The decline in problem-solving and innovation ability
leading to overreliance on automatic or inadequate strate-
gies or complete abandonment of goal pursuits.
Alternative Neuropsychological Origins of ADHD
Since the executive dysfunction model’s publication, several
theoretical models attribute additional and alternative cognitive
and behavioral sources for developing ADHD symptoms. Presented
are four theories reviewed by Johnson et al. (2009). Included is
Brown’s EF model, often cited in treatment literature.
Brown’s EF Cluster Model
Similar to Barkley, Brown’s (2005, 2013, 2014) model also
places EF impairments and their relationship with self-regulation
at the core of ADHD (Brown, 2006). However, the definition of EFs,
the origin of impairments, and their impact on individuals are
considerably different. Instead of Barkley’s heavily theoretical
approach, Brown’s cognitive–behavioral model builds from
research based on intensive clinical interviews with individuals
diagnosed with ADHD and their families. Brown identifies
ADHD as a complex syndrome of developmental impairments of
EFs (Brown, 2013). Defined as capacities enabling engagement in
successful independent self-serving behavior (Lezak et al., 2004),
EFs in this model are not hierarchical but clusters of cognitive
functions that interact dynamically and continuously for self-
management in the following ways:
• Activation: organizing, prioritizing, estimating time, and
activating action to work.
• Focus: focusing, sustaining, and shifting attention to tasks.
• Effort: regulating alertness, sustaining effort, and proces-
sing speed.
• Emotion: managing frustration and regulating emotions.
• Memory: utilizing working memory and accessing recall.
• Action: monitoring and self-regulating action.
This self-management system of the brain provides the mecha-
nism for self-regulation, defined as the ability to change oneself and
exert control over one’s inner processes specifically by organizing
actions toward goals, managing emotional distress, obeying laws,
and internalizing social standards of both moral and competent
behavior (Vohs & Baumeister, 2004). Brown’s model views the
coordinated efforts of EFs as a networked guidance system, much
like a computer (Carver & Scheier, 2016) or the conductor of an
orchestra as opposed to a separate concept of conscious sense of self,
a difference that Barkly challenges as a passive view of the organism
in existing models of EF (Barkley, 2012). Brown sets this manage-
ment system firmly in the unconscious or System 1 of Kahneman’s
(2011) behavioral “thinking fast and slow” theory via “automatic-
ity,” defined as rapid activation of attitudes, emotions, or behaviors
that emerge in a specific context without directed conscious thought
(Bargh, 1994; Brown, 2014). Brown (2014) cites LeDoux (1996)
and Dodge (1991), who highlight the primacy of unconscious
emotional processing as the energetic, motivational force, or “hot
EF” (Castellanos et al., 2006) that drives cognitive activity and
shapes experience and action. Circuits of the limbic system, specifi-
cally the amygdala, are designated as instantaneous processers that
assess emotional reactions and appraise the level of reward or threat
concerning instinct and memories of past experiences to designate
how much attention should be allotted (Damasio, 1999). Brown
differentiates his model from Barkley’s by broadening his emotional
modulation scope from inhibition of negative emotions to include
value for positive emotions, such as interest, attraction, and desire.
Dopamine, a neurotransmitter particularly sensitive to pleasure and
reward, is highlighted as a signaller of important stimuli to the PFC,
which selects action plans, including storing in working memory
(Brown, 2005). Dopamine increases triggers interest and indicates
reward, and therefore motivation that creates a feedback loop to
sustain engagement—a hedonic view of well-being. This system
effortlessly draws upon personal memory of past experiences and
learned skills to automatically produce complex responses in a
variety of contexts, reducing the need to make conscious deliberate
decisions. The ability to use emotion-based stored working memory
to hold things in mind and utilize that information to direct current
action, or make choices, via “cool EF” (Castellanos et al., 2006) is
crucial for the guidance of EFs and self-regulation (Brown, 2005).
In this model, ADHD persistence in impairments is attributed to
EFs’ location in unconscious automaticity (Brown, 2013), making
medication treatment essential. The situational variability of im-
pairments and adaptive problems in day-to-day activities that char-
acterize ADHD is presented as the evidence of impairments in
cognitive management networks, not independent cognitive func-
tions (Brown, 2006). Neurobiologically, four areas are highlighted
as interfering with effective self-regulation. Limitation to the inter-
active communication networks due to white matter differences is
suggested as the origins of working memory deficits (Castellanos &
Proal, 2012; Cortese et al., 2012, 2013). This deficit is evidenced by
a single fMRI study in children where performance differences in
parieto-temporal activation and fronto-striatal and fronto-cerebellar
connectivity during vigilant attention were normalized compared to
controls with methylphenidate (K. Rubia et al., 2009). Differences
in increasing deactivation of the DMN during active attention tasks
(Fassbender et al., 2009) are identified as impairments in the
coordination of dynamic shifts in rate and rhythms of bran cell
oscillations (Brown, 2014). This impairment is evidenced by a
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
single fMRI study in children of increased default-mode suppression
with methylphenidate (Peterson et al., 2009). Neurodevelopmental
delay in maturation (P. Shaw et al., 2007), or less maturity in
emotional management than peers, is highlighted as damaging to
learning, relationships, and self-esteem in years when education and
preparation for adult life are key. Inadequate release and control of
dopamine and norepinephrine and its impact on the delay of
reinforcement (Swanson et al., 2011) are suggested as origins in
deficits in motivation and sustained effort. Studies indicating
improvements in utilization of working memory and functional
connectivity using methylphenidate are presented as beneficial
(Prince & Wilens, 2009), although Brown admits few studies
address the impact of medication treatment on emotion regulation
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(Brown, 2014).
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Sergeant’s State Regulation Hypothesis
Similar to Barkley, Sergeant (2000, 2005) identifies inhibition as
a central deficit in ADHD. However, disinhibition is not unique to
ADHD, and therefore the State Regulation Hypothesis of ADHD
(Sergeant et al., 1999) focuses on the activation of inhibition and
highlights the energetic state as an origin for performance deficits.
Based on human vigilance and performance research, the cognitive-
energetic model (Sanders, 1983) is used to act as a bridge between
“top-down” and “bottom-up” theories of functioning and addresses
the heterogeneity found in ADHD (Sergeant, 2005; Sergeant et al.,
2003). Sanders (1983) identifies three levels of information proces-
sing: management, energetic, and cognitive processing, divided into
two functional categories: process or computational mechanisms of
attention and state or energy for activation. Cognitive information
processing operates in four stages: encoding, search, decision, and
motor organization. State processes are categorized into three
energetic pools: effort, arousal, and activation.
The effort is the energy necessary to meet task demands and is
required when the organism experiences stress, an intervening
variable response when the organism’s current state does not
meet the required state for task performance. Emotions, defined
as physiological feedback, are indicators of stress. The effort is
given state primacy in this model as it excites and inhibits the arousal
pool and the activation pool, highlighting its role in motivation and
response contingencies (e.g., threat/reward)—a hedonic view of
well-being. The effort is associated with the hippocampus, and pupil
dilation measures cognitive load and effort engagement (Sergeant
et al., 1999).
Arousal is a phasic, or rapid, adaptation to stimuli that indicates a
rate of change, described as “time-locked” (Pribram & McGuinness,
1975; Sergeant et al., 1999). Arousal is associated with the mesen-
cephalic, reticular formation, and amygdala regions of the brain.
Activation is a tonic or slow physiological readiness to respond to
stimuli associated with the basal ganglia and corpus striatum. The
process by which stimuli may be maintained and manipulated in a
short-term buffer is called working memory (Baddeley, 1996).
Planning, monitoring, and error detection and correction are the
management mechanism’s role, or EF, associated with the PFC.
These levels’ interaction demonstrates how the cognitive-energetic
model encompasses both “top-down” and “bottom-up” self-
regulation processes.
Sergeant (2005) highlights that deficits in ADHD have been
identified at all three levels of the model: cognitive response
579
mechanisms, energetic activation and effort mechanisms, and man-
agement, or EF, system deficits. The influence of effort highlights
Sergeant’s relationship between effort and the activation pool over
response choice, motor preparation, or motivation. Research has
demonstrated that individuals will delay motor preparation until
they gain maximum payoff for effort with minimum energy alloca-
tion (Hackley & Miller, 1995). Children with ADHD have exhibited
sensitivity to response contingencies, rewards, and deficient
response organizations in laboratory testing, particularly when
stimuli are presented slowly, which is demonstrated as a rapid
decline in task efficiency concerning the event rate (Sergeant
et al., 1999). Because the event rate influences motor activation
in the cognitive-energetic model, Sergeant defines ADHD as an
energetical state dysfunction with insufficient effort allocation.
Allocation of energetic resources is probably strongly associated
with the availability of particular neurotransmitters (Sergeant et al.,
2003). Thus, symptoms will increase or decrease depending on the
task parameters and the state of the individual with ADHD, and for
Sergeant, this could explain ADHD heterogeneity.
Sonuga-Barke’s Delay Aversion/Dual Pathway Theory
In contrast to the EF deficit models, Sonuga-Barke’s delay
aversion/dual-pathway theory (Sonuga-Barke, 1994, 2003, 2004;
Sonuga-Barke et al., 1992) began as a simple single deficit model
based on motivational factors. Based on the laboratory evidence,
this theory initially identified ADHD impulsivity as the expression
of a natural preference for immediacy in children with ADHD,
particularly when a choice is an option. Because this preference is
expressed even when rewards are offered following delay, it is
interpreted as a biologically based shortened delayed reward gradi-
ent (Sonuga-Barke, 2003). It is suggested that children with ADHD
have automatic “bottom-up” hypervigilance to emotionally or
motivationally relevant environmental cues indicating opportunities
to escape from delay (Sonuga-Barke et al., 2004). The ability to
delay gratification has high social–cultural importance in terms of
socialization, and this model theorizes that parental intolerance of
“impulsiveness” creates an association over time of delay with
negative responses. Consequently, children with ADHD develop
a negative emotional response to delay or delay aversion (Sonuga-
Barke, 2003).
Inattention and hyperactivity are also expressions of this prefer-
ence, presented as a “top-down” process designed to modify the
subjective experience of time passing and reduce the experience of
delay. The aim is to effectively “speed up time” in situations without
choice by moving attention to non-task-related aspects in the
environment (Sonuga-Barke, 2003; Sonuga-Barke et al., 1996).
Neurobiologically, delay aversion is placed within a motivational
or affective reward circuit to include the ventral striatum (nucleus
accumbens [NAccs]), frontal regions (notably the anterior cingu-
late), and orbitofrontal cortex. The circuit is completed by connec-
tions in the ventral palladium, structures in the thalamus, and the
amygdala. The meso-limbic neurotransmitter dopamine, which we
have seen is involved in ADHD, is a key modulator for reward
signaling in this circuit (Sonuga-Barke, 2004).
In light of evidence that children with ADHD also demonstrate
EF deficits, Sonuga–Barke incorporated Barkley’s (1997b) response
inhibition hypothesis rather than current EF theories. Defined as
“higher-order, top-down, cognitive processes that allow appropriate
 580 CHAMP, ADAMOU, AND TOLCHARD
task set, maintenance and shift, and that facilitate the flexible pursuit
of future goals” (Sonuga-Barke, 2004, p. 1232), EFs generally and
response inhibition specifically are regarded in this model as critical
for self-control, emotional regulation, and cognitive flexibility. It is
suggested that motivational and cognitive development could be
impacted by the experience of challenges in effective engagement
with tasks and environments that require inhibition-based executive
processes. As with delay, the negative social–cultural responses to
task failure may lead to “executive-task aversion,” impacting intrin-
sic motivation and reducing interaction with these tasks, therefore
limiting opportunities to develop executive skills. Neurobiologi-
cally, EFs are placed within an executive circuit to include the
PFC, the dorsal neostriatum (caudate nucleus), the basal ganglia,
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and the dorsomedial thalamus excitatory glutaminergic cells. The
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meso-cortical neurotransmitter dopamine is a key circuit modulator
(Sonuga-Barke, 2004).
This model argues that neither the executive circuit nor the reward
circuit could fully account for the behavioral self-regulation chal-
lenges evidenced in ADHD. However, a head-to-head study of the
two models indicates that both are distinct, separate processes, and
can be identified in ADHD (Solanto et al., 2001). Sonuga-Barke
suggests that a dual-pathway model recognizes the heterogeneity
that comes with ADHD and may indicate additional ADHD sub-
types. More recently, a third pathway has also been suggested
involving temporal processing deficits (Sonuga-Barke et al., 2010).
Sagvolden’s Dynamic Developmental Theory
Similar to Barkley (1997b) and Sonuga-Barke (2004), Sagvolden
et al. (2005) also postulated that ADHD is grounded in issues with
response inhibition and delay aversion. However, this model’s
origin is represented as hypofunctioning dopamine systems that
may account for all the symptoms in the hyperactive/impulsive and
combined ADHD subtypes. The dynamic developmental theory
(DDT) is based on the work with animal models in behaviorism
(Skinner, 1953, 1971) and defines ADHD as arising from two faulty
behavioral processes: altered reinforcement of novel behavior and
deficient extinction of reinforced behavior (Sagvolden et al., 2005).
Based on the research with methylphenidate (Grace, 2001), the
DDT argues that issues with ADHD arise from naturally occurring
abnormally low levels of tonic dopamine transmission or slow
stimulus adaptation, leading to naturally elevated phasic dopamine
transmission or rapid stimulus adaptation. It is suggested that phasic
dopamine has two subcomponents: a fast component signaling a
primary response for engagement with the expectation of reward
before confirmation, defined as erroneous “reward prediction,” and
an intermediate subcomponent involved with behaviors such as
movement, reward, punishment, stress, and sex (Schultz, 2002).
Phasic dopamine is released as a pulse or spike response. Tonic
dopamine is located in the extrasynaptic space but is low concen-
tration and tightly regulated. It is too low in concentration to
stimulate receptors, and it is strong enough to exert a continuous
downregulation and modulation of phasic response spikes. (Grace,
2001) Tonic dopamine is thought to be regulated by frontal cortical
sensory neurons to the NAccs via the DLPFC, an area attributed to
being responsible for working memory. The DDT suggests that
ADHD arises from dysregulation of tonic/phasic dopamine control,
causing stunted dopamine phasic responses despite low-tonic levels
(Sagvolden et al., 2005). Lower levels of existing tonic dopamine in
this model, combined with a smaller striatal volume, could also
account for deficits in working memory (Castellanos, 2001).
The DDT indicates dopamine hypofunctioning in ADHD impacts
three dopaminergic networks responsible for self-regulation: the
meso-limbic, the meso-cortical, and the nigrostriatal. Impact on the
meso-limbic network could result in altered reinforcement and
extinction behavioral processes, interfering with establishing behav-
ioral stimulus control and acquisition of verbal instructions to set
rule-governed behavior. This behavior produces a shorter delay-of-
reinforcement gradient, resulting in the delay aversion described by
Sonuga-Barke (2004). Because reinforcement and extinction behav-
ior acquisition processes require tonic and phasic dopamine to be
successful, naturally occurring lower tonic dopamine in ADHD will
require increased phasic dopamine release to achieve reinforcement.
Similarly, normal tonic but reduced phasic dopamine release asso-
ciated with a reinforcer will result in less efficient reinforcement.
This model claims this describes the “motivation” issues seen in
ADHD, and therefore reinforcers must be stronger and more salient
to control behavior. Extinction deficits, or inability to stop ongoing
behavior despite lack of reinforcement, accounts for Barkley’s
(1997b) response inhibition in this model. Meso-cortical network
disturbances result in attentional deficiencies that increase behav-
ioral control and direct action toward long-term goals. Deficiencies
in the nigrostriatal network are associated with impaired motor
control and habit formation through nondeclarative memory, which
may be partly responsible for Barkley’s (1997b) response inhibition.
In other words, reinforcement of behavior is only successful if the
consequences are perceived within a limited time window. Hypo-
functioning dopamine systems may impact this time window length
in ADHD, leading to limited stimulus control around attention,
preferences for short sequences of behavior leading to motor
impulsiveness, and deficient maladaptive behavioral extinction
leading to excessive behavior or hyperactivity. In this model,
EFs are “untangled” into motor impulsiveness and cognitive impul-
siveness due to the slower acquisition of longer sequences of
behavior and difficulty with the extinction of previously reinforced
behaviors (Sagvolden et al., 2005).
The DDT hypothesizes that the interplay between behavior and
environment at different times of life will generate ADHD hetero-
geneity. For the person with ADHD, the impact of individual
variations in dopamine functioning on learning processes and
behavior will result in developmental delays in identifying connec-
tions between situational or instructional demands and behavior
leading to problems anticipating appropriate situationally relevant
behaviors and lack of development of self-directed speech for
guiding behavior. The DDT highlights that ADHD impacts individ-
ual and family relationships, particularly when the parents may also
have ADHD. Although a non-ADHD parent may assist with
developing stimulus control in their child by providing frequent
and immediate reinforcers, it is unlikely to be achieved by an ADHD
parent (Sagvolden et al., 2005). Cultural and social value for
behavioral self-control, learning to use time efficiently, and foresee
consequences of the behavioral impact on socializing, gaining an
education or gaining employment generate challenging expectations
for those with ADHD. In Western cultures, permissible unwanted
behaviors in childhood are expected to extinguish by adulthood.
According to this model, an adult with ADHD will have acquired
many maladaptive behaviors that will be difficult to change. Inter-
estingly, the DDT also recognizes a successful side of this
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
neurobiology as a positive, creative individual who directs their
energy toward work, defined as a type A personality (Sagvolden
et al., 2005).
Nigg et al.’s Multiple Pathway Model
Unlike other ADHD theories, the focus of the multiple pathway
model (Nigg, 2017; Nigg, Karalunas, et al., 2020; Nigg & Casey,
2005; Nigg et al., 2004) is less on the etiology of ADHD and more
on clarifying the heterogeneity and different developmental trajec-
tories represented by comorbidities found in ADHD populations
(Nigg et al., 2004). To accommodate these differences, this model
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highlights the integration of cognitive and affective neuroscience
This document is copyrighted by the American Psychological Association or one of its allied publishers.
through considering components of cognitive control, affect regu-
lation, and their mutual influence on one another in self-regulation
and in development (Nigg & Casey, 2005). Maturation leads to
neural organization and increasing hierarchical specialization and
differentiation in cognitive neural systems. Prediction, or learned
expectations of temporal and contextual cues, is based on the
attentional responses from infancy (Saffran et al., 1996). Cognitive
control is defined as behavioral regulation, or the ability to adjust
behavior based on these cues and suppress inappropriate behaviors.
This ability arises out of four basic circuits identified in neurode-
velopment (Amaral, 1986):
• reflexive, or “where” orienting, guided by a parietal–
thalamic circuit;
• alerting and vigilance, or “when” orienting, guided by
noradrenergic activation of right-lateralized circuitry,
including the cerebellar–cortical circuits;
• reinforcement learning and reward response, guided by
fronto-limbic circuitry; and
• effortful regulation and voluntary planning of behavior and
cognition, which involves frontostriatal circuitry (Nigg &
Casey, 2005).
This model links reinforcement and reward and effortful regula-
tion into a third “what” orientation based on the mutual reliance on
fronto-striatal loops and dopaminergic modulation, forming affect-
related neural systems that detect events’ emotional significance.
These circuits facilitate the adjustment of action when predictions of
what is being presented are violated. It is the “when” and “what”
orientations requiring voluntary or effortful control that this model
highlights as challenging to activate efficiently in ADHD, seen as a
failure to form accurate predictions resulting in difficulty adjusting
behavior to what is presented when something unexpected happens.
The actions from these inaccurate predictions account for ADHD
behaviors that are continued inappropriately for the context where
the outcome/consequences are misjudged, or when action has its
effect mispredicted. In other words, breakdowns or disruption in
linking the known correct behavior with the current context lead to
inaccurate expectations, resulting in less top-down cognitive control
being recruited, affecting planning, maintenance of thoughts and
actions over time, and regulation of affect (Nigg & Casey, 2005).
Here, the model agrees with Sagvolden et al. (2005) that disruptions
in these systems may also lead to inefficiencies in developmental
learning and socialization, interfering with the benefits received
581
from an expected level of parental support or correction and
therefore integration and self-regulation (Figures 3–6).
In highlighting the reciprocal connection between emotions and
the recruitment of cognitive control, the core focus is on updating
goal states by continual contextual processing of frequency, timing,
and emotional valance of information which disrupts goal-directed
behavior in ADHD. This model associates the influence of positive
emotional valance, an expectation of reward, and negative emo-
tional valance, or nonexpectation of reward, with excessive
approach motivation and withdrawal/nonapproach motivation con-
textual behaviors. This behavior is defined as temperament or
categories of traits involving affective reactivity and regulation.
Thus, inattention–disorganization can be mapped to effortful con-
trol, hyperactivity to activity level, and impulsivity to negative/
positive approach (Nigg et al., 2004).
This model suggests that there are advantages to temperament
parallels with ADHD behaviors: temperament coding would be
advantageous in the early stages of development to identify pre-
cursors of ADHD and illuminate risk factors or as an outcome
moderator. Maturational changes in temperamental traits combined
with experience also give rise to personality traits in adulthood
similar to maturational changes in ADHD symptoms (Nigg et al.,
2004). Therefore, this model argues that temperamental tendencies
may lead to ADHD, and ADHD may be identified as a common
phenotype clinical outcome of several developmental pathways
(Nigg & Casey, 2005; see Figure 7a). Alternatively, ADHD has
multiple identifiable pathways with slightly different phenotypic
outcomes (see Figure 7b): prediction breakdowns leading to top-
down weakness, arousal regulation, and cognitive control, described
as “executive functioning” difficulties (Barkley, 1997b); extreme
positive approach tendencies leading to problems in reinforcement
learning (Sagvolden et al., 2005) with minimal to no EF deficits;
breakdowns in response inhibition, or cognitive control, and affec-
tive responding, or a poorly regulated approach system (Sonuga-
Barke, 2003, 2004); and also faulty avoidance learning leading to
impulsive and antisocial behavior and psychopathy (Nigg & Casey,
2005; Nigg et al., 2004). Further work on this model has extended to
the broader field of psychopathology using network modeling
(Borsboom & Cramer, 2013; McNally, 2016) which assumes that
the accumulation or “clusters” of symptoms generates a syndrome
rather than a latent disorder or trait (Nigg, Karalunas, et al., 2020;
Nigg, Sibley, et al., 2020).
Critical Review of Theories
Issues in ADHD Neurobiology
The cognitive–behavioral theory-based conceptualization of
ADHD is prominent in advances in neuroscientific research. In
ADHD, differences in structure and function of the brain are
presented as evidence of deficits leading to hyperactivity, impulsiv-
ity, and inattention. These include size differences in the pallidum,
thalamus, caudate nucleus, putamen, NAccs, amygdala, and hippo-
campus (Hoogman, Buitelaar, et al., 2017); abnormalities within
dopaminergic networks, specifically the meso-limbic (Posner et al.,
2013; Volkow et al., 2011); differences in cortical maturation rate
(Shaw et al., 2006, 2007); as well as altered activity in the PFC,
blood flow to limbic areas via the striatum, and activation of
hippocampus, insula, and anterior cingulate (Barkley, 2014a).
 582 CHAMP, ADAMOU, AND TOLCHARD

Figure 3
Brown’s EF Model
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Note. EF = executive function. Adapted from Brown, T. E. (2005). Attention Deficit Disorder:
The Unfocused Mind in Children and Adults. Yale University Press. Copyright 2005 by Yale
University Press. Adapted with permission. See the online article for the color version of
this figure.

Despite these findings, neuroimaging data remain correlational
(Kooij et al., 2019), and recent meta-analysis indicates no significant
difference in brain structure between adults with ADHD and con-
trols (Hoogman, Buitelaar, et al., 2017; Wolfers et al., 2019). In
addition, there are several persistent concerns and considerations
regarding ADHD neurobiology (Figures 8–10).
Issues With ADHD and EF
Recent research has shown that no single EF deficit is high
enough to support executive dysfunction as the cause of all cases
(Boonstra et al., 2005; Castellanos et al., 2006; Nigg, Stavro, et al.,
2005; Nigg, Willcutt, et al., 2005; Posner et al., 2020; Willcutt et al.,
2005) and neuropsychologically identified EF is not associated with
deficient emotional self-regulation in ADHD (Surman et al., 2015).
Criticism of EF weaknesses highlights that the complexity of
neurocognitive processes in executive tasks makes isolating the
exact locus of dysfunction difficult using current EF task testing
designs (Willcutt et al., 2005). However, Barkley (2012, 2014a) and
Brown (Barkley & Brown, 2008; Brown, 2005, 2006, 2009) argue
that laboratory-based neuropsychological tests of EF impairments in
adults with ADHD are limited in scope due to their focus on single
variable isolation. They recommend assessing the ability to perform
complex everyday self-managed tasks as a more appropriate way to
measure individual executive functioning. Consequently, Barkley’s
(1997b, 2012) EF model is still promoted as clinically useful for case
formulation, treatment planning, and intervention design (Ramsay,
2016, 2020).
Altered Brain Activity in ADHD
Although altered brain activity in ADHD has been noted in
neuroimaging research, it has received limited positive attention.
In several studies, brain activity in ADHD engaged differently or
oppositely to controls. Selective attention tasks showed robust
bilateral activity in the ventrolateral PFC (BA 45) and insular cortex
compared with controls and unilateral activation of caudate, puta-
men, thalamus, and pulvinar, indicating potential recruitment of a
different response pathway (Bush et al., 1999). In switch tasks,
adults with ADHD more strongly engaged the right middle temporal
gyrus, dorsal anterior cingulate cortex (dACC), precuneus, lingual
gyrus, and the left precentral gyrus (supplementary motor area) and
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY 583

Figure 4
Sergeant’s Cognitive-Energetic Model
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Note. Adapted from “The Cognitive-Energetic Model: An Empirical Approach-Deficit

Hyperactivity Disorder”, by J. Sergeant, 2000, Neuroscience and Biobehavioral Reviews,
24(1), pp. 7–12 with permission from Elsevier (http://dx.doi.org/10.1016/S0149-7634(99)
00060-3). See the online article for the color version of this figure.

insula, demonstrating that those with ADHD display different
fronto-striatal and parietal activation than controls during the per-
formance of an executive control task (Dibbets et al., 2010). In
working memory tasks, a diffuse network of regions was activated
rather than right PFC regions, including the parietal, precuneus, and
occipital lobe, indicating that individuals used more visual strategies
in this aurally presented task suggesting a system more reliant on
visual strategies and response to visual stimuli (Fassbender &
Schweitzer, 2006). In research on an inhibitory paradigm and delay
task, activations were seen in right pre and postcentral gyrii, right
inferior parietal lobe, and right caudate instead of bilateral frontal
areas of the PFC suggesting activation differences may reflect
differences in strategies for task performance (Fassbender &
Schweitzer, 2006; K. Rubia et al., 2000). When progressive
time-on-task activation was examined in a working memory task,
increases in activation in the right lenticulate, left parahippocampal
gyrus, and cerebellum was shown over time, possibly indicating a
reliance on motor regions (Schweitzer et al., 2004). Complex
cognitive function tasks showed activation of the right side of
the basal ganglia rather than left, leading to the speculation of

Figure 5
Sonuga–Barke’s Delay Aversion/Dual Pathway Model

Note. Adapted from “The Dual Pathway Model of Attention Deficit/Hyperactivity Disorder (AD/HD): An Elaboration of Neuro-Developmental
Characteristics”, by E. J. S. Sonuga-Barke, 2003, Neuroscience and Biobehavioral Reviews, 27(7), pp. 593–604 with permission from Elsevier
(http://dx.doi.org/10.1016/j.neubiorev.2003.08.005). See the online article for the color version of this figure.
 584 CHAMP, ADAMOU, AND TOLCHARD

Figure 6
Sagvolden’s DDT Model
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Note. DDT = dynamic developmental theory. Adapted from “A Dynamic Developmental Theory of Attention-Deficit/Hyperactivity Disorder (ADHD)
Predominantly Hyperactive/Impulsive and Combined Subtypes”, by T. Sagvolden, H. Aase, E. B. Johansen, & V. A. Russell, 2005, Behavioural Brain
Research, 28, pp. 397–468 (http://dx.doi.org/10.1017/S0140525X05000075). Copyright 2005 by Cambridge University Press. Adapted with permission.
See the online article for the color version of this figure.

differences in how this region is used to perform tasks (Durston et
al., 2003; Shafritz et al., 2004).
It has long been recognized that the dopaminergic reward path-
way is altered in ADHD. However, findings also showed a strong
positive correlation with the motivational measure of Positive
Emotionality and D2/D3 receptor availability in the midbrain in
adults, indicating the importance of intrinsically interesting activi-
ties in improving motivation (Volkow et al., 2011).
In resting-state connectivity analysis, connections between dorsal
(DAN) and ventral (VAN) attentional networks were less segregated
functionally in ADHD than controls, with hyper connections with
the VAN. Increased coupling with the VAN and the salience
network (SN) produces an altered saliency attribution mechanism
in ADHD. Interestingly, the connection between the DMN and the
SN was intact and unaffected (Sidlauskaite et al., 2016). The SN has
been identified as crucial in identifying biologically and cognitively
relevant endogenous and external stimuli to adaptively guide behav-
ior between large-scale brain networks, with the anterior insula
particularly key in salient event detection signaling reward, moti-
vation, and affective saliency (Menon, 2015). More recently,
research in altered interaction between large-scale networks showed
hyperactivation with the DMN during cognitive paradigms leading
to excessive spontaneous “mind wandering” in ADHD (Bozhilova
et al., 2018; Posner et al., 2015). Although excessive mind wander-
ing can be impairing, mind wandering has been positively correlated
with creativity tasks such as the generation of novel and useful ideas
(Carson et al., 2003; Fink et al., 2012) and better creative output due
to a broad attentional focus (Kasof, 1997; Mendelsohn, 1976;
Zedelius & Schooler, 2015).
Investigations of stop-signal tasks and stop-signal reaction time
indicate that inattentive and hyperactive symptoms represent an
entirely different integration of distributed processing in ADHD that
recruits resources used in task-directed performance by typically
developing (TD) individuals. It is hypothesized that this style of
processing is not amenable to the reinforcement learning models that
appropriately describe neural function in TD (Chevrier & Schachar,
2020). Cordova et al.’s (2020) findings from the comparison of
subgroups showed that biological differences exist and are not
entirely attributable to a global theme of over- or under-connected
functional networks but display a fundamentally different organi-
zation attributable to more complex mechanistic interactions across
networks.
Heterogeneity
Heterogeneity remains an unresolved problem, leading research-
ers to infer that causes of ADHD may be distinct and also shared
with other conditions as well as TD (Cordova et al., 2020; Feczko
et al., 2019; Nigg, Karalunas, et al., 2020; Posner et al., 2020).
Heterogeneity in ADHD is demonstrated both etiologically and
phenotypically in multiple dimensions including neurobiological,
developmental, psychosocial, and emotional/cognitive self-
regulation (Luo et al., 2019; Nigg, Sibley, et al., 2020). The
polygenic liability of ADHD adds to its complexity, considering
the overlap or co-occurrence with other phenotypes and psychiatric
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY 585

Figure 7
The Multiple Pathway Model
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Note. ADHD = attention-deficit hyperactivity disorder; PFC = prefrontal cortex. Part labels and images adapted from “Temperament and Attention Deficit
Hyperactivity Disorder: The Development of a Multiple Pathway Model,” by J. T. Nigg, H. H. Goldsmith, & J. Sachek, 2004, Journal of Clinical Child and
Adolescent Psychology, 33(1), pp. 42–53 (http://dx.doi.org/10.1207/S15374424JCCP3301_5). Copyright 2004 by Cambridge University Press; and “An
Integrative Theory of Attention Deficit/Hyperactivity Disorder Based on the Cognitive and Affective Neurosciences,” by J. T. Nigg, & B. J. Casey, 2005,
Development and Psychopathology, 17(3), pp. 785–806 (http://dx.doi.org/10.1017/S0954579405050376). Copyright 2005 by Cambridge University Press.
Adapted with permission. See the online article for the color version of this figure.

disorders (Cross-Disorder Group of the Psychiatric Genomics
Consortium, 2013; The Brainstorm Consortium, 2018) and a recent
Genome-Wide Associaton Study that has identified 12 independent
significant associated genetic loci (Demontis et al., 2019). However,
affect sizes are small for each individual gene despite multiple gene
involvement (Faraone & Larsson, 2019; Luo et al., 2019; Nigg,
Sibley, et al., 2020). Although heterogeneity is acknowledged in the
DSM-5 by specifying three presentations: mostly inattentive, mostly
hyperactive, and combined (APA, 2013), some theories account for
all these presentations (Brown, 2013; Nigg, Karalunas, et al., 2020;
Sergeant, 2005; Sonuga-Barke, 2003), whereas others characterize
them as separate conditions (Barkley, 2014c; Sagvolden et al.,
2005). Conceptualizations of ADHD currently recognize the
dimensionality of the disorder, yet there is very little research on
positive attributes such as hyperfocus, creativity, divergent thinking,
curiosity, courage, transcendence, and resilience (Boot, 2017; Boot
et al., 2020; Redshaw & McCormack, 2022; Sedgwick et al., 2018;
H. A. White & Shah, 2006, 2011, 2016). Phenomenological quali-
tative studies of the lived experience of ADHD indicate that interest
is associated with meaning and a sense of “flow” (Csikszentmihalyi,
1975), mainly when working with or assisting others (Ek &
Isaksson, 2013); that aspects such as persistence and perfectionism
can be identified as undervalued resources, and that those with
ADHD strive to find a healthy balance and develop strategies
(Bjerrum et al., 2017). However, these positive aspects tend to
be perceived as “individual strengths” which are encouraged in
treatment, rather than unifying positive features of ADHD (Champ
et al., 2021).
The ADHD Paradox or Context Variability
Research has also identified that while there is a persistence of
core symptoms in ADHD, there is significant variability in context
(Brown, 1995, 2014; Hirvikoski et al., 2011). Individuals with
ADHD demonstrate consistently good, sustained attention on tasks
which are engaging or “interesting” but symptoms increase in
situations synonymous with low stimulation or boring activities,
often resulting in delay aversion and inattention (Antrop et al., 2000;
Boonstra et al., 2005; Hoza et al., 2001; Johansen et al., 2002;
Roberts et al., 2014; Wender, 1995; Zentall et al., 1985). However,
characterizations of ADHD often define this behavior as “stimulus
seeking” and tend to focus on the inability to engage with non-
stimulating tasks. Research also shows a correlation in ADHD with
a need for autonomy, defined in this context as a freedom of choice
(Dimic & Orlov, 2014; Houghton, 2006; Partridge & Williams,
2008; Young, 2000). Studies show that those with ADHD per-
formed better in working environments where autonomy was
supported, sometimes highlighted as entrepreneurship (Boot,
2017; Toner et al., 2006). Young and Bramham (2012) specifically
 586 CHAMP, ADAMOU, AND TOLCHARD

Figure 8
The Taxonomy of SDT Regulatory Styles
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Note. SDT = self-determination theory. Adapted from “Approaching and Avoiding Self-Determination: Comparing Cybernetic and Organismic Paradigms of
Motivation,” by R. M. Ryan, & E. L. Deci, in R. S. Wyer, Jr. (Ed.), Perspectives on Behavioural Self-Regulation (pp. 193–215), 1999, Routledge. Copyright
1999 by Taylor & Frances Group. Adapted with permission. See the online article for the color version of this figure.

stress that for those with ADHD to succeed, they must define their
structures and boundaries. There is little research into the motiva-
tional influences of interest and autonomy in ADHD other than as a
reward.
Theoretical Influence on Current Treatment Approaches
Traditionally, the primary goal of research on self-regulation in
ADHD is the management and reduction of the experience of
negative emotions, which are presented as problematic, destabiliz-
ing, and leading to dysregulation and overwhelm. Therefore, the
focus of the nonpharmacological interventions has been to improve
self-regulation by the cognitive reframing of maladaptive schema,
habituation of behavioral management skills via continuous rein-
forcement, and development of cognitive regulation skills in atten-
tion shifting and positive reappraisal (Philipsen et al., 2010;
Ramsay, 2020; Ramsay & Rostain, 2015; Safren et al., 2005;
Solanto, 2010; Tuckman, 2009; Young & Bramham, 2012;
Zylowska et al., 2008). The reappraisal goal is to identify negative
responses early in the emotional experience and consciously alter
them to positive perspectives (Gross, 2013). Although this skill is
helpful in some contexts, such as managing an immediate crisis or
when another’s safety or emotional stability is of primary concern,
such as a child, the process of reappraisal involves avoidance of the
experience of emotion in preference to minimizing negative affect
(Wolgast et al., 2013). However, being cognitively led, reappraisal
requires an additional cognitive cost, as described in “effortful
coping” (K. Ochsner et al., 2002), implying a high demand of
performance for those with ADHD considering effort avoidance
(Roberts et al., 2014) and an inability to allocate sufficient cognitive
effort are both considered core characterizations of ADHD
(Sergeant, 2000). Reappraisal also is shown to be less accessible
as a resource when emotional intensity is high (Gross, 2013),
and intensity of emotional dysregulation is identified as a core
component of impairment in ADHD (Barkley, 2014a; Corbisiero
et al., 2013).
SDT: A New Perspective
Extensive research in multiple areas of human functioning has led
to the understanding that ADHD presents motivation, engagement,
and self-regulation issues. Understanding interest and its role as a
motivational factor in ADHD is key to gaining a new perspective on
ADHD behavior. However, motivational research has highlighted
interest as a central affective marker of intrinsic motivation (Ryan &
Deci, 2017). SDT presents intrinsic motivation as the spontaneous
tendency “to seek out novelty and challenges, extend and exercise
one’s capacity, explore, and learn” (Ryan & Deci, 2000, p. 70). SDT
is an empirical organismic approach to personality development that
investigates people’s inherent growth tendencies as a basis for self-
motivation and personality (Ryan & Deci, 2000). At the core of SDT
is the assumption that human development includes an innate, active
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
Figure 9
ADHD Altered Neural Processing Model
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
Note. ADHD = attention-deficit hyperactivity disorder; EF = executive function; DMN = default-mode network; SN = salience network. See
the online article for the color version of this figure.
tendency toward integration of structures, functions, and experi-
ences resulting in greater effectiveness, organization, and unity in
functioning (Ryan, 1993; Ryan & Deci, 2017). Defined as organis-
mic integration, SDT describes organization as both a fundamental
biological principle and a perspective reflected in multiple psycho-
logical traditions such as Piaget’s (1971, 1981) ideas of organization
expressed as propensities toward assimilation; Freud’s (1923) con-
cept of synthetic function of the ego; White’s (1959, 1963) descrip-
tion of inherent independent ego energy manifesting in intrinsically
motivated activities; and Rogers (1963) primacy for the tendency
toward actualization as a basic motivational tendency underlying
behaviors.
SDT and Self-Regulation
SDT defines the self as a synthetic function of the psyche,
reflecting this inherent tendency toward organization and integration
as an active process. Unlike social-cognitive approaches which
define self as an object perceived by oneself or another (self-
concept), supported by mechanisms for governing action (self-
schemas), SDT cites McAdams (1990, 1996, 2013) view of the
“self-as-subject” phenomenally experienced both as a center of
experience and the initiator and regulator of volitional behavior
(Ryan & Deci, 2017). This “self-as-process,” or autonomous func-
tioning, is defined in SDT as having the freedom to choose actions
that align with the interests, values, and a sense of meaning
originating in the internal self-concept. Freedom, in this instance,
is not defined as independence from external influences, but a higher
order coordination of component systems into a relative unity and
acting from that organized vantage point (Ryan et al., 1997).
Autonomy, meaning “self-governing,” is considered central to
healthy development as it functions both phenomenologically
587
and structurally to organize integration and regulate actions to
integrate new functions, values, narratives, preferences, and regula-
tions (Ryan & Deci, 2017). Thus, self-regulation in SDT is synon-
ymous with autonomy and “disturbances in autonomy” are equated
to self-regulation disturbances (Ryan et al., 1997).
Traditionally, the exploration of issues with healthy self-
regulation focuses on the control and management of behavior.
Instead, SDTs organismic approach orients questions about moti-
vation and behavior toward what supports human functioning and
flourishing. According to the SDT, the quality of an individual’s
motivation and vitality depends on what resources they have been
able to draw from their exchanges with their environment to
maintain, support, and enhance their existence or satisfy their needs.
While it is clear that organisms have biological deficit needs (Hull,
1943) that, when satisfied, will return an organism to equilibrium,
SDT postulates that there are also basic psychological needs that do
not require deficiencies to motivate action. When satisfied within
cultural, interpersonal, and developmental contexts, basic psycho-
logical needs facilitate growth, integrity, and well-being and, when
frustrated, generate psychological harms (Ryan & Deci, 2017). SDT
identifies three innate basic psychological needs—autonomy, com-
petence and connection, or relatedness—which, when satisfied,
allow optimal function and growth. As previously described, auton-
omy is the feeling of willingness and volition with respect to
behaviors. Competence is defined as feeling effective with interac-
tion in social environments or, more precisely, experiencing support
and opportunities for the exercise, expansion, and expression of
capacities and talents. Relatedness is defined as feeling connected
and having a sense of belonging, referring to both experiencing
others as responsive, and sensitive (Ryan & Deci, 2017). SDT
suggests that people can become self-determined, make choices, and
manage their lives independently when their needs for competence,
 588 CHAMP, ADAMOU, AND TOLCHARD
Figure 10
ADHD Self-Regulation and Task Engagement
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Note. ADHD = attention-deficit hyperactivity disorder. See the online article for the color version of this figure.
relatedness, and autonomy are fulfilled (Deci & Ryan, 1985). Acting
volitionally to achieve goals and satisfy needs experienced as
intentional and thus personally caused is the basis of self-determi-
nation. SDT defines self-determination from the phenomenological
tradition as a willed action caused “as an initial act of the ego-center
itself” (Pfander, 1967, p. 20) differentiated from acts caused by
external agents. However, this autonomous action could occur even
when experiencing external pressures if one agrees to act in that way
(Ricoeur, 1966).
As an organismic approach, SDT is concerned with both goal
achievement and the nature and motives of goal adoption. SDT
highlights that there are process differences for goals that have
different origins. The satisfaction of the basic psychological needs
will be consistent with the achievement of some goals but not others,
and thus “all goals are not created equal” (Ryan et al., 1996).
Critically, SDT cites Heider’s (1958) and de Charms’ (1968) work
on the psychological construct of perceived locus of causality and its
impact on motivation: the degree to which autonomy is experienced
as a salient sense of personal causation determines the intrinsic
nature of the action. Individuals who are intrinsically motivated
engage with activities because they are interested in and find them
inherently satisfying. Exploratory “seeking” behaviors, experienced
as curiosity, interest, sensation seeking, and search for meaning,
produce a sense of immediate positive feedback on progress when a
challenging task at an achievable or optimum level is mastered. This
sense of gaining competence, or “flow” state (Csikszentmihalyi,
1975), is seen as a process of continually seeking and reducing
information gaps in knowledge or problem-solving (Di Domenico &
Ryan, 2017). Motivation to engage and regulate activity is height-
ened in some domains, forestalled, or conflicted in others, and some
opportunities will amplify or diminish interest, meaning SDT
recognizes both social contextual and within-person variations in
regulatory functioning (Ryan & Deci, 2017).
In light of these potential variations and in contrast to other
models of self-regulation, SDT recognizes three regulatory styles
that are characteristic of human functioning: relatively autonomous
and integrated modes, relatively controlled and introjected (nonau-
tonomous) modes, and absence of regulation (and motivation) (Deci
& Ryan, 1985; Ryan & Deci, 2017). Integrative regulation repre-
sents natural human development to actively internalize and assimi-
late social norms and regulations for healthy functioning.
Independent reproduction of socially and culturally accepted assim-
ilated behaviors, attitudes, and values reflect the process in which
extrinsic behaviors become a part of an aspect of an individual’s
mind and motives. Research indicates that three facilitating factors
lead to internalization: a meaningful rationale, so individuals find
value in the activity; acknowledging potential negative feelings; and
highlighting choice. A key conclusion from this research was the
importance of the relationship between the subject’s behavior and
feelings: the more positive the relationship, the more integrated the
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
regulation (Deci et al., 1994). SDT views healthy emotion regulation
as including rich access to positive and negative emotions as
informational inputs that assist in both the choice and self-guidance
of actions. Taking an active interest in emotional responses, ex-
pressing them, and using them as a built-in feedback system to
provide physiological, cognitive, and motivational signals that
inform behaviors and goals to satisfy basic psychological needs
is a key part of integrated emotional regulation (Roth et al., 2019).
This system supports an individual to exercise potential, find
meaning, connect with others, and express vitality—a eudaimonic
view of wellness (Ryan et al., 2006).
In addition, SDT outlines that rewards, contingencies, and pres-
sures attached to specific outcomes can be experienced as control-
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ling rather than based on the individual’s autonomous choice. The
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opposite of autonomy in SDT is not dependence but heteronomy,
defined as controlled by outside forces (Ryan & Deci, 2017).
Behaviors that are introjected or externally motivated to establish
internal control over the self are simply responses to the environ-
ment rather than internalized and establish an expectancy (implicit
or explicit) that the contingency is in effect. When introjected,
behaviors are experienced as an internal, controlling force—a sense
that one “should” or “must” do the behavior. Therefore, the beha-
viors will not be sustained over time because they are dependent on
the maintenance of these external or internal pressures and contin-
gencies for reliable occurrence. Controlling regulation results in
unstable self-esteem (Kernis & Paradise, 2002; Ryan & Brown,
2013) and suppression of negative emotions impairing the ability to
disclose, listen to, or deal with them effectively (Roth et al., 2014).
Absence of regulation, or amotivation, is defined as a state where
one is not motivated to behave or behaves in a way not mediated by
intentionality. Amotivation potentially results from two sources:
lack of perceived competence, or believing that acting will either not
achieve the desired outcome or that the behavior cannot be per-
formed, or perceiving a lack of value or interest in the behavior. The
first is recognized in social–cognitive theory (Bandura, 1996), but
the second is also recognized in SDT as an absence of interest and
utility, leading to a lack of motivation to act (Ryan & Deci, 2017).
Emotionally, amotivation can be experienced as dysregulation,
where individuals’ daily functioning is impacted by their inability
to manage negative emotions and consequently feel overwhelmed
and therefore engagement with others and the environment is
impaired (Roth et al., 2014). SDT highlights that intrinsic motiva-
tion only occurs when individuals experience self-determined
action, perceived competence, and relational responsiveness and
security, or relatedness. Therefore, autonomy is “fragile,” and must
be supported for optimal development and expression (Ryan et al.,
1997). Not all goals will result in positive consequences for the
individual, and individuals may discontinue practice once pressure
or controlling elements are removed (Ryan & Deci, 2008). There-
fore, autonomy-supportive environments are critical to integrated
self-development (Ryan et al., 2016).
SDT and Neuroscience
Recent research in motivational neuroscience has identified brain
structures and neural pathways, establishing a neural basis for
motivational states. Neuroscience literature highlights that intrinsic
motivation arises from spontaneous satisfaction one experiences
while engaged in a task or intrinsic rewards, and this sense of task
589
satisfaction is what makes the experience of engagement with a task
enjoyable or interesting. The anterior insula generates these intrinsic
satisfactions, and the extent to which an activity is considered
interesting is represented by activity in the anterior insular cortex,
making it the key structure in intrinsic motivation (Reeve & Lee,
2019b). Engagement with an environmental activity that allows a
person to feel volition, effectance, and connection also produces
need-satisfying spontaneous satisfactions, showing that basic psy-
chological need satisfaction is indicated by anterior insular and
striatum activations (Lee & Reeve, 2017; Reeve & Lee, 2019a).
Studies in dopaminergic function show that task-related feedback is
registered even in the absence of external rewards (Tricomi &
DePasque, 2016) and that salience-related dopaminergic activity
drives curiosity and desire for information (DeYoung, 2013).
Therefore, SDT proposes that intrinsic motivation is associated
with activity in the dopaminergic value system (Di Domenico &
Ryan, 2017). The SN, involves the anterior insula, dACC, and
subcortical nodes in the amygdala, NAccs, substantia nigra, and
ventral tegmental area (Menon, 2015). The SN is believed to receive
motivationally significant dopaminergic information from several of
its main structures and subcortical nodes, which is integrated with
sensory input from the environment and viscera for “bottom-up”
detection of contextually relevant events in self-regulation. It is
suggested that a function of the SN is to act as a dynamic hub to
modulate activity between two other large-scale brain networks that
support cognitive functions. The first is the DMN, which has major
nodes in the medial PFC and posterior cingulate cortex and is active
during passive resting states and involved in internally focused self-
referential cognition, spontaneous cognition, and mind wandering
(Buckner et al., 2008). The DMN is also associated with introspec-
tive attentional orientation related to mentalizing and emotional
processing (Gusnard et al., 2001) and the maintenance of a sense of
self (Gusnard, 2005; Sonuga-Barke & Castellanos, 2007). The
second is the central executive network (CEN) which includes
the DLPFC and the posterior parietal cortex and is active during
cognitively demanding, externally focused tasks and involves work-
ing memory and EFs. Neuroimaging studies support the SDT theory
that activities involving intrinsic motivation recruit the salience and
CENs, while suppressing the DMN, specifically activity within the
midbrain, anterior cingulate cortex, and bilateral insula in response
to free-choice (autonomy) cues (Di Domenico & Ryan, 2017).
SDT Etiology of ADHD
SDT and ADHD
Applying the organismic approach of SDT to our current under-
standing of ADHD clinical presentation, neurobiological research,
and treatment design and outcomes has the potential to offer a new
conceptualization and approach. Recognizing that those with
ADHD actively seek to improve engagement with their environment
to achieve integration and self-actualization fundamentally alters the
ADHD discourse. This perspective also highlights the importance of
understanding the task or activity targeted for engagement and its
relationship with both ADHD neurocognitive abilities and the
individual’s regulatory state. Seen from an SDT perspective,
ADHD etiology could be described as neurobiologically altered
approaches to processing and task engagement, supported by struc-
tures that have been primarily associated with salient event detection
 590 CHAMP, ADAMOU, AND TOLCHARD
and affective functioning. The following presents a positive etiology
of ADHD within a practical framework for treatment design and
outcomes.
Altered Neural Processing
Research has demonstrated that there are neurobiological differ-
ences in development, function, and information processing in
ADHD. A prolonged developmental trajectory, enhanced connec-
tivity, and clustering of regions associated with emotional proces-
sing and smaller volumes in areas related to cognitive control
networks can lead to less efficient “top-down” management and
dominant cognitive self-regulation. However, recent research sup-
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ports an entirely different integration of distributed processing with
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different neural representations and subjective experience of task-
related stimuli in ADHD (Chevrier & Schachar, 2020).
Altered connectivity between brain networks has been indicated
in ADHD, specifically altered connectivity among the CEN, SN,
and DMN (Castellanos & Proal, 2012; Cortese et al., 2012; Gao et
al., 2019). Research indicates that hypofunctioning dopaminergic
systems resulting in low-tonic/high-phasic dopamine transmission
in ADHD may increase exploratory-seeking behaviors (Di
Domenico & Ryan, 2017; Sagvolden et al., 2005). The altered
dopaminergic activity also results in semisuppression of the DMN
during cognitive tasks (Fassbender et al., 2009; Tomasi et al., 2009)
and hyperconnectivity between the SN and the DMN (Hart et al.,
2012, 2013; Sidlauskaite et al., 2016; Viering et al., 2021). Increased
connectivity with the SN demonstrates a susceptibility to higher
salient stimuli (Götting et al., 2017; Sidlauskaite et al., 2016) and
reduced connectivity between the orbitofrontal cortex and ventral
striatum results in less cognitive regulatory control (Posner et al.,
2013). A high level of sensitivity to affective stimuli and weaker
cognitive functionality would indicate that self-regulation is more
affect dominant than cognitive dominant within the bidirectional
relationship. This sensitivity may also influence the differences in
temporal processing associated with ADHD, as research into models
of time processing or the “internal clock” highlight the dependence
of time awareness on attentional executive control processes (Droit-
Volet et al., 2018) and the premotor cortex (Droit-Volet, Monceau,
et al., 2020), the influence of dopaminergic activation of cortico-
striatal circuits including attention and working memory (Toplak
et al., 2006) and the effect of emotion and arousal on the magnitude
of time distortions (Droit-Volet, 2018; Droit-Volet, El-Azhari,
et al., 2020; Droit-Volet et al., 2018; Vasile, 2015). Research
also shows that individuals with ADHD experience cognitive
domain-dependent neuro-functional impairments in different neural
networks depending on the cognitive context (Dibbets et al., 2010;
Hart et al., 2012).
Motivation and Engagement
This neurobiological foundation impacts the effectiveness of the
task approach and engagement in multiple dimensions. Distortions
in estimating external time longitudinally combined with suscepti-
bility to higher salient stimuli would lead to a wider and more
immediate attentional awareness resulting in an overinclusive pro-
cessing style (Acar & Runco, 2012; Eysenck, 1993, 1994; White,
2018). This style would suggest a tendency for chaotic cognitions
and divergent thinking, an aspect of creative cognition shown to be a
potential positive outcome of ADHD particularly in the dimension
of idea generation (Cardello & George, 2021; Girard-Joyal &
Gauthier, 2021; Steele et al., 2021), although findings are inconsis-
tent and more research is needed (Boot, 2017; Hoogman et al., 2020;
Sedgwick et al., 2018; Taylor et al., 2018; White, 2018; H. A. White
& Shah, 2006, 2016). ADHD individuals would also be strongly
intrinsically motivated by an interest in seeking environmental
engagement and positive feedback from problem-solving (Di
Domenico & Ryan, 2017; Sagvolden et al., 2005). Task approaches
that are inherently interesting and therefore increase dopaminergic
activity will generate positive affective feedback—they will feel
easy or more engaging, and positive experiences of competence can
lead to a sense of “flow” or hyperfocus (Deci & Ryan, 2000; Di
Domenico & Ryan, 2017; Ek & Isaksson, 2013; Sedgwick et al.,
2018). However, task approaches requiring dopaminergically sup-
ported suppression of the DMN and efficient activation of the CEN
will be more challenging for those with ADHD. From an SDT
perspective, an individual with ADHD will feel less competent at
engaging with these task approaches, as they will require more effort
to engage and potentially maintain engagement.
As we have seen, curiosity and interest are concurrent with
dopaminergic release and are key factors in intrinsic motivation
(DeYoung, 2013; Gruber et al., 2014; Ryan & Deci, 2017).
Therefore, if the challenge is too difficult to feel competent, lacks
clarity, or the interest is too low, a natural reaction would be to
not engage with these challenging tasks but to initiate seeking
behaviors to facilitate engagement with tasks or activities that
feel more achievable or interesting. In controlled environments
where an individual is unable to autonomously pursue activities
of interest, this engagement-seeking behavior could appear as
the hallmark ADHD indicators of hyperactivity, impulsivity,
and inattention.
Psychopathology
SDT states that psychopathology arises from autonomy depriving
and thwarting environments (Ryan et al., 2016). Evidence indicates
that adults with ADHD have experienced a lifelong history of need
frustration (Oram et al., 2020). They find low autonomy environments
that are highly structured or controlled challenging, and will experi-
ence boredom, are made redundant or change jobs frequently (Boot et
al., 2020; Dimic & Orlov, 2014; Houghton, 2006). Inconsistencies in
personal management, organizational skills, and underachievement
provide negative evidence for competence or efficacy in achieving
goals for personal growth (Bokor & Anderson, 2014; Goodman,
2007; Mitchell et al., 2013; Newark & Stieglitz, 2010). Rejection,
lack of acceptance, or understanding of differences in behavior creates
a significant impact on interpersonal skills and social connections or
relatedness (Houghton, 2006; Toner et al., 2006).
Developmentally, and depending on the social–cultural context,
an individual with ADHD will encounter more and more task
approaches that require DMN suppression and CEN activation,
in other words, those that require independent management, cogni-
tive control, and behavioral inhibition leading to an increase in
symptomatic behaviors and coping mechanisms (Fleming &
McMahon, 2012; Fortes et al., 2014; Knouse & Fleming, 2016;
Nigg, Sibley, et al., 2020; Ramsay & Rostain, 2008b; Wender,
1995). Lack of understanding of the altered processing in ADHD
results in inefficient learning (Chevrier & Schachar, 2020) and
 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, THEORY
dominance of standardized reinforcement models to develop skills,
habits, and routine behaviors are experienced as controlling or
amotivating. Therefore, behaviors often become introjected or
remain extrinsically motivated by social or environmental domains
and will cease once circumstances alter or change (Roth et al., 2019;
Ryan & Deci, 2008).
Occasional successful strategy design and application is often
followed by turmoil (Toner et al., 2006) as lack of awareness of
neurocognitive and psychological needs leads to an incoherent
understanding of the building blocks for success. Many individuals
will describe experiences of constant stress or crisis, high anxiety, or
a desire to procrastinate or be “under pressure” to complete tasks
(Nadeau, 2005; Ramsay et al., 2016; Safren et al., 2004; Wolf et al.,
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2009). This framework suggests that through salient affect-based
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responses to either the task or the approach or both depending on
context (Posner et al., 2020), the ADHD individual is aware of a lack
of interest or challenges with engagement. The internal conflict
between natural-seeking behaviors, the need to complete the task
and lack of skills or understanding to support achievement generates
a stress response. Exposure to psychosocial stress is associated with
dopaminergic output (Bloomfield et al., 2019; Payer et al., 2017),
providing the additional dopaminergic “push” needed for the
ADHD individual to suppress the DMN and activate the CEN to
utilize the reinforcement model-based skills to engage with the task.
With a lack of access to alternative strategies, and because stress
generates a dopaminergic response leading to intermittent success,
over time, the individual with ADHD becomes unconsciously
dependent on anxiety (“flight”) or frustration and aggression
(“fight”) as a motivational coping strategy. Chronic exposure
also leads to compensatory downregulation (Bloomfield et al.,
2019; Payer et al., 2017), therefore active use of the stress cycle
as a motivational strategy generates long-term comorbid anxiety and
depression, which is often the first presentation clinicians will see in
undiagnosed ADHD (Bolea-Alamañac et al., 2014; Kooij et al.,
2019; Lackschewitz et al., 2008; Nigg, Sibley, et al., 2020; Solanto
et al., 2008).
The impacts of the altered neural processing on embodied time
(Droit-Volet, Monceau, et al., 2020) also have a developmentally
negative impact on perceived competence. More affect-dominant
self-regulation combined with an altered perception of embodied
time may result in reduced sensitivity to longer durations but a
higher response to shorter durations, as the experience of time
fluctuates according to arousal and affect (Droit-Volet et al.,
2013). Many socially presented skills, habits, and planning pro-
cesses are predicated on spontaneous time awareness that evaluates
long durations, which rely on efficient cognitive processing and
working memory (Droit-Volet, 2018; Droit-Volet et al., 2013).
Inefficient cognitive processing in ADHD makes this resource
unreliable, leading to over- or under-estimation of embodied time
and therefore interfere with cognitive-dominant strategies and skill
use, impacting time management, planning, prioritization, and
estimation (Barkley, 2006; Brown, 2013; Roberts et al., 2014).
Treatment Design and Outcomes
Research has shown that reinforcement models may be inap-
propriate for learning in ADHD (Chevrier & Schachar, 2020).
Therefore, recognizing the impact of altered neural processing and
using an SDT approach to the etiology of ADHD would
591
significantly affect treatment design and outcomes. Treatment
design would include assessing an individual’s regulatory style,
contextualizing task-based need frustration, and clarifying where
supportive behaviors need to become internalized. Identification of
variations in regulatory functioning could highlight keys for
individual challenges and context-specific treatment application.
Therapist characterization of ADHD as an alternative or neurodi-
verse processing style requiring an unconventional skill set could
support the individual development of self-acceptance and self-
esteem by recognizing biological and individual strengths and
resources.
Psychoeducation on the importance of the relationship among
natural-seeking tendencies, interest and motivation, and the impact
of engagement of the stress cycle as a motivational tool would be
key to increasing self-awareness. Developing skills to interpret
information from emotional responses as feedback to inform beha-
viors would facilitate awareness of the intention and need satisfac-
tion behind these behaviors concerning the context, increasing a
sense of choice and development of autonomous self-regulation.
Acknowledging the reduced sensitivity to longer time durations
would generate exploration of tools and methods for supportive time
management. Understanding the tendency toward natural-seeking
behaviors and the importance of positive feedback from problem-
solving would influence goal selection, strategy development, and
outcome measures for achievement.
Summary and Future Work
Theoretical perspectives strongly influence the etiology of symp-
toms, research focus, and treatment guidance in ADHD. This
influence extends beyond academia and mental health decision-
making and impacts public perception and the development of the
individual’s self-concept and identity. The dominant theoretical
paradigm of ADHD provided by cognitive–behavioral theory pre-
sents an etiology limited to a deficit-focused, motivationally
hedonistic perspective that generates treatment outcomes focused
on symptom reduction and emotional and behavioral control.
Alternative theoretical approaches are needed that incorporate
conceptualizations with outcomes aiming to strengthen positive
psychological factors and support growth and well-being.
We have introduced a theoretical framework for ADHD etiology
grounded in SDT to provide an alternative view of the research data
and a positive approach to well-being and treatment outcomes. The
main propositions from this framework are as follows:
1. That all humans have an inherent growth tendency and
thus have a natural inclination to seek engagement with
their environment to satisfy basic psychological needs
for autonomy, a sense of competence, and belonging or
relatedness.
2. ADHD neurocognitive differences in hypofunctioning
dopaminergic systems, efficiency of cognitive processes,
and susceptibility to higher salient and affective stimuli
may result in:
a. seeking behaviors designed to facilitate environmental
engagement and interest, interpreted in some contexts
as hyperactivity, impulsivity, and inattention,
 592 CHAMP, ADAMOU, AND TOLCHARD
b. self-regulation processes that are more affect domi-
nant than cognitive dominant in the bidirectional
relationship, and
c. less efficient cognitive control generating under- or
over-estimations in embodied time, creating distortions
in longitudinal time awareness and a higher sensitivity
to short durations, and therefore a wider and more
immediate attention (or overinclusive) processing style.
3. These differences are observable in task engagement and
motivation as:
a. a tendency toward chaotic and also creative cogni-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tions, including the potential for divergent thinking
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and idea generation,
b. active participation in task approaches that are ori-
ented toward problem-solving, are intrinsically inter-
esting, and provide positive and more immediate
feedback, and
c. negative outcomes if a task approach requires more
cognitive effort than feels achievable and autonomous
approach design is unsupported, generating feelings
of lack of competence.
4. Psychopathology arising from a lifetime of need frustra-
tion, experiences of social rejection and lack of under-
standing due to stigma, and environmental and social
demands to prioritize task approach processes based on
the reinforcement models of learning. Attempts to engage
a consistently high level of cognitive effort generate a
dependency on stress responses (“fight or flight”) based on
internal conflict to provide a dopaminergic “push” to
activate this cognitively dominant skillset, often with
inconsistent results further reinforcing a negative self-
concept and identity.
We propose that viewing ADHD behaviors through an SDT lens
provides an opportunity to shift the focus in research, diagnosis, and
treatment outcomes from deficit identification and symptom control
to neurodivergent difference identification and integration. This
theoretical shift addresses the challenges in ADHD neurobiological
research, heterogeneity, and context variability in the following ways:
• If the motivational drive behind ADHD symptomatic
behaviors is an organismic need for engagement and
growth, then an awareness and understanding of the
origin, or “why,” of the behavior is critical to identifying
the need, and challenges with context variability are
reframed as issues with engagement.
• If self-regulation is more affect dominant than cognitive
dominant in ADHD, then developing skills to increase
awareness and understanding of emotional responses as
informational in relation to behavior is key to ADHD self-
awareness, self-monitoring, and self-regulation.
• If psychopathology arises not from neurobiological deficits,
but altered neuro-processing combined with need frustration,
then clarity of ADHD-altered neuro-functioning process
attempts to satisfy basic psychological needs, act via intrinsic
motivation, and engage in self-regulation requires further
research.
• Shifting the focus away from deficit-based models of
functioning alters the perspective on heterogeneity, provid-
ing opportunities to research ADHD etiology and behaviors
in relation to other presentations within a neurodiversity
paradigm and investigate the potential benefits of ADHD-
altered neuro-processing.
• If goal design, progress, and achievement utilize basic
psychological need satisfaction as outcomes, then pro-
cesses for goal achievement, particularly long-term goals,
can accommodate ADHD neurobiological time distortion.
Using this SDT-based framework as a foundation, our following
projects focus on understanding potential positive aspects of
ADHD, and a pilot of a treatment approach. Recent research high-
lights the critical nature of lived experience accounts, particularly
in neurodivergent populations (Grant & Kara, 2021; Milton &
Bracher, 2013; Rosqvist et al., 2020b; Stenning & Rosqvist,
2021). Examining ADHD lived experience through the lens of
SDT may provide new insights into the positives offered by
ADHD. Following analysis of this research, a treatment approach
is designed to include psychoeducation in ADHD-altered neuro-
processing, understanding the relationship between ADHD neuro-
biology and environmental engagement, and skills development in
mindful self-awareness, task identification, and goal design and
development. Treatment outcomes would include symptom reduc-
tion and quality of life and critically also include measures for
autonomy and self-determination.
Working with a trained therapist in an autonomy-supportive
manner, we suggest that individuals with ADHD could better
understand how they function, differentiate between biological
needs and individual needs, and develop an alternative skillset to
improve self-regulation, integrate experiences, and act volitionally
in ways that feel more self-determined resulting in an integrated
positive ADHD identity and self-concept.
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Received September 10, 2021
Revision received July 17, 2022
Accepted September 8, 2022 ▪